Sealed Personal Health Care Records (Cover Sheet)
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Sealed Personal Health Care Records (Cover Sheet) Form. This is a Washington form and can be use in Domestic Relations Statewide.
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Tags: Sealed Personal Health Care Records (Cover Sheet), DRPSCU 09.0260, Washington Statewide, Domestic Relations
Superior Court of Washington
County of
In re:
No.
Petitioner(s),
and
Respondent(s).
Sealed Personal Health Care
Records
(Cover Sheet)
(SEALPHC)
Clerkâs 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:
[]
Relates to the past, present, or future physical or mental health condition of an individual
including past, present, or future payments for health care.
[]
Involves genetic parentage testing.
Submitted by:
Notice: The other party will 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.
Sealed Per Health Care Records (SEALPHC) - Page 1 of 1
WPF DRPSCU 09.0260 (6/2006) - GR 22(b)(3),(f)
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