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Sealed Personal Health Care Records (Cover Sheet) - Washington
| Sealed Personal Health Care Records (Cover Sheet) Form. This is a Washington form and can be used in General Superior Court Thurston Local County . |
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q EXPEDITE (if filing within 5 court days of hearing) q Hearing is set: Date: ______________________________________ Time: SUPERIOR COURT OF WASHINGTON FOR THURSTON COUNTY FAMILY AND JUVENILE COURT In re _______________________________________________ Petitioner(s) and _______________________________________________ Respondent(s) No. _____________________ Sealed Personal Health Care Records (Cover Sheet) (SEALPHC) Clerk's Action Required Sealed Personal Health Care Records (List documents below and write "Sealed" at least one inch from the top of the first page of each document.) Records or correspondences that contain health information that: r r Relates to the past, present, or future physical or mental health condition of an individual including past, present, or future payments for health care. (MDR) Involves genetic parentage testing. (RSBT) DATED: _______________________. Submitted by: Signature: Print Name: Address: Phone No.: ________________________________ ________________________________ ________________________________ ________________________________ (_______)________________________ NOTICE: The other party may have access to these health care records. If you are concerned for your safety or the safety of the children, you may redact (block out or delete) information that identifies your location. Other parties may have access to these health care records through a court order. You may also redact the following information: Social security number, driver's license number, telephone number, and financial account numbers. Sealed Per Health Care Records (SEALPHC) - Page 1 of 1 WPF DRPSCU 09.0260 (6/2006) - GR 22(b)(3),(f) F: \FORMS\Sealed\FL forms \Sealed Personal Health Care Records.doc , 8/25/06 American LegalNet, Inc. www.FormsWorkFlow.com
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