Sealed Personal Health Care Records {012}

Superior Court of Washington, County of In re: Petitioner/s (person/s who started this case): No. Sealed Personal Health Care Records (Cover Sheet) (SEALPHC) Clerk's action required. For use in Family Law and Guardianship cases. And Respondent/s (other party/parties): Sealed Personal Health Care Records (Cover Sheet) Use this form as a cover sheet to keep your personal health information private from the public. On the first page of each document, write the word "SEALED" 1 inch from the top of the page. Check the documents you are attaching to this cover sheet to be sealed: Health records of any kind (including correspondence) related to a person's physical or mental condition, or payment for health care. Genetic test records for parentage. Submitted by: Sign here Petitioner or his/her lawyer Respondent or his/her lawyer Print name (if lawyer, also provide WSBA #) Important! The other person and the lawyers in your case can see your sealed documents. If you need to keep your address information private for safety reasons, you may cross out or delete your address information. GR 22(b)(3), (g) Mandatory Form (05/2016) FL All Family 012 Sealed Personal Health Care Records p. 1 of __ American LegalNet, Inc. www.FormsWorkFlow.com