Medical Examiner - Authorization for Release of Information

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Name of Decedent:

Date of Birth:

Date of Death Month:

Date of Death Day:

Date of Death Year:

Relationship to the decedent:

Spouse

Personal Representative

Relative

Other

Relative (Specify relationship) or Other

Agency/Individual:
Street Address:
City:
State:
Zip:
Phone Number:	Ext:
Email:

Reports to be delivered by:

Mail Email In Person Pickup

Specific Information to be released from the Medical Examiner of Washington County:

Photographs are not generally provided without a court order to be released.

	Toxicology		Final Autopsy Report
	Investigative Report		Other:		Other Information

I understand that the health information disclosed as a result of this authorization may no longer be protected
by the federal privacy standards and the health information might be re-disclosed without my permission.
I understand I have the right to:

Receive a copy of this authorization.
Revoke this authorization at any time by giving written notice of my revocation to the Agency/Individual listed above
(the Disclosing Agency). I understand that revocation of this authorization will not affect any action taken in reliance
on this authorization before receiving my written notice of revocation.
Right to receive a copy of records to be released: I have the right to inspect and copy the health information to be used
or disclosed pursuant to this authorization.

This authorization will remain in effect until the following date(s): 10/16/2027 or one (1) year.

Name:

Date:

I agree and understand that by checking this box I am signing the Authorization for Release of Information Form,
all electronic signatures are the legal equivalent of my manual/handwritten signature