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.

Preliminary Autopsy Report Final Autopsy Report
Toxicology Investigative Report
Other:

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): 02/14/2027 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