Patients & Visitors
Health Care Forms
Advance Directives
Advance directives are papers you write ahead of time for when you might be ill and cannot speak for yourself. Advance directives tell people caring for you the kinds of treatment you would want. In Washington State, there are two kinds of advance directives: a living will and a durable power of attorney for health care.
When you write advance directives, you should give copies to all your doctors, to loved ones, and maybe carry a card in your wallet that says that you have it. Also, you may give a copy of your advance directive to Stevens Hospital medical records department to put on file for you. Bring a copy when you are admitted to the hospital, if you don't have one on file. Copies of advance directives are just as legal as the original text you signed. If you become so ill you cannot speak for yourself, your doctor will use this information to honor your wishes. You may choose to have a lawyer help you make your advance directives, but it is not required.
Advanced directives forms are available upon request or may be downloaded below. Please ask your nurse if you are interested in completing an advance directive. Having both a living will and a durable power of attorney for health care is best. A durable power of attorney for healthcare may also be useful in more situations than the living will, because it is good at any time you cannot speak for yourself, not just when you are dying or permanently unconscious (the only times a living will may be used).
You may change or cancel your advance directives at any time by just telling your doctor or by writing a new one, dating it and destroying all copies of the old one. It is very important to make sure your loved ones and your doctor know when you have completed or changed your advance directives. Stevens medical records department also will need a copy of your revised document.
Release of Information–Getting Copies of Your Medical Record
Stevens Hospital keeps a record of the healthcare services provided to you. You may ask to see and copy that record. You may also ask to correct that record. This healthcare facility will not disclose your records to others unless directed by you or unless authorized or compelled by law to do so. You may see your record or get information about it by contacting the Health Information Management Department at 425.640.4202. The department is open Monday through Friday, 8:00 a.m. to 4:30 p.m.
Written permission must be submitted before health information can be released. Please use the form below to make sure we know what information you want us to release and to whom we can release it. If you cannot download the form, call 425.640.4202, and we will mail a copy to you.
>> Download Authorization for Release of Protected Health Information (PDF)
Submitting Your Request Form
A complete and signed authorization form can be submitted the following ways:
Mailed to the address below:
Stevens Hospital
Health Information Management Department
21601 76th Avenue West
Edmonds, WA 98026
Faxed to: 425.640.4434
Delivered in person to the address above. The Health Information Management Department is located on the 4th floor.
Note: Please bring a form of ID with photo and signature when picking up record copies.
Stevens Hospital has contracted with iod to do all copying and billing for release of information requests. There is a fee for the copies made by iod (information on demand). The schedule of charges below is in compliance with the Washington State Uniform Health Care Information Act, RCW 70.02, Section 102(12), and an authorization does not have to be honored until the fee is paid:
$22.00 |
Clerical Fee | |
$ 0.96 |
Per page for the first 30 pages | |
$ 0.73 |
Per page for additional pages over 30 | |
$ 2.00 |
Certification Fee | |
| Postage or delivery actual cost | ||
| Applicable Washington State sales tax |
Please call 425.640.4202 to check the status of your request or for additional information. Please allow 7 to 14 business days for your request to be processed.
Minor Consent Form
A document to be filled out by a legal guardian, 18 years of age or older. This document allows the minor to be given medical treatment.
>> Download minor consent form (PDF).
Living Will
A living will is a signed and dated legal document stating the medical care you want or do not want if you become so ill you are unable to make your own decisions. It is not used unless you are terminally ill or are in a permanent unconscious state.
Two people must witness your signature on the living will. The witnesses must not be related to you, they must not be named in your last will and testament, and they must not be your doctor or any of your health care givers, or someone to whom you owe money. A living will does not have to be notarized.
>> Download living will form (PDF).
Register Your Living Will Today!
Most people have clear ideas about their end of life preferences, but few share them with family or physicians. For Washingtonians there is good news. The Living Will Registry is designed to help you put your treatment wishes in writing and in a place accessible to your attending health care provider.
Registering is FREE and easy. People of all ages should prepare a living will. Take the simple steps to protect your treatment wishes and give yourself peace of mind. Your family will be comforted knowing your living will documents are immediately available and your treatment preferences followed during times of serious illness.
The online registry stores:
Health Care Directives
Durable Power of Attorney for Health Care
Mental Health Advance Directives
Physician Orders for Life Sustaining Treatment
Emergency Contract Information
Disagreements are all too common when family members feel unsure about their loved one’s final wishes. Take charge of your life and register today!
For more information visit www.doh.wa.gov/livingwill or call toll free 800.525.0127. Now is the time!
Durable Power of Attorney for Health Care (DPOA)
A durable power of attorney for health care is a signed and dated legal document naming another person to make medical decisions for you if you are unable to speak for yourself. That person could be a relative, friend, significant other, or anyone you choose except your doctors or your health care givers. Also, you can add instructions about any treatment that you want and/or any treatment you do not want. At this time, when you make a durable power of attorney for health care in Washington you do not have to have witnesses or a Notary Public. However, we suggest you either have two witnesses who know you to sign the paper, or else have your signature notarized.
If you have not named someone in your durable power of attorney (DPOA) for health care, then, by state law, the following people (in the order noted below) would be the ones to decide for you. If there is more than one person at the highest level of authority, all must agree to withdraw or withhold treatment. That means, for instance, if you don't have a spouse and you have more than one child over 18 years old, they will have to agree when the decision is about withholding or withdrawing treatment for you. No one else besides the people on this list can decide for you unless you have named them as your DPOA.
- Your spouse. If none then:
- Your adult children (at least 18 years of age). If none then:
- Your parents. If none then:
- Your adult brothers and sisters.
>> Download durable power of attorney for health care decisions form (PDF).
Physician's Orders for Life-Sustaining Treatment POLST)
The POLST form is a recent addition to end-of-life decision making in Washington State. This form is for adults with serious health conditions. Your doctor can write your wishes clearly as medical orders. It is a bright green form, intended to go with the patient as medical orders. That is, it can be used at home, in care facilities and in the hospital. It can direct treatment by emergency medical services (EMS) personnel and others. The POLST form asks about preferences for resuscitation, comfort care and treatment. To be valid as medical orders, it must be signed by the doctor and the patient, or the patient's representative. You may request the form from a social worker if your doctor's office does not have one. Copies of the form may be used, too. Eventually, the POLST form will replace the EMS No-CPR, described next.
Emergency Medical Services No-Cardiopulmonary Resuscitation (EMS No-CPR)
In Washington State, there is a legal way to choose not to have cardiopulmonary resuscitation (CPR) when you are not in the hospital and your heart stops. Its called EMS-NoCPR. If you have an EMS No-CPR paper, signed by you or your representative and your doctor, or are wearing the EMS No-CPR bracelet, the EMS people will offer comfort and care to you and everyone near you, but will not try to revive you. The document and bracelet are also honored at Stevens Hospital. But the best thing to do is to talk with your doctor about having a POLST (described above), which is a more useful document and will soon replace the EMS No-CPR.
Organ/Tissue Donation
Any person 18 years of age or older may become an organ or tissue donor. If you wish to donate organs or tissues, you may say so when you renew your driver's license, or when you obtain an identification card through the State Licensing Department. In either case, it becomes part of a permanent record called the donor registry and ensures your wishes will be honored, if at all possible. If you decide to be a donor, be sure to discuss your decision with your family, doctor and friends. For more information visit the donor registry website at www.donatelifetoday.com.
