Washington Adoptee Consent or Refusal of Release of Identifying Information (DOH 422-096)
Official state formAdoptionForm DOH 422-096Free downloadLast verified November 10, 2026
An adult adoptee completes this form to state whether they want contact with biological relatives and whether their identifying information may be released. The Center for Health Statistics at the Washington State Department of Health places it in the sealed adoption file.
Who can use this form
- The adoptee named in the record, age 18 or over
- The adoptee completes and signs the form under penalty of perjury
- The preference can be changed at any time by sending a new form
What to send with it
- The completed and signed form, filled out based on the adoptive information
- Your current legal name, mailing address, phone and email
Where to send it
- Mail to
- Center for Health Statistics PO Box 47814 Olympia, Washington 98504-7814
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- May 2018
- Source
- Official government page