Financial 4 –

Sealed Health Cover Sheet

FL All Family 012: Sealed Personal Health Care Records (Cover Sheet)

Quick Instructions:
1. Attach your documents to the cover sheet. Include
health records that relate to your financial situation.

2. Write "SEALED" on the first page of each attached

document, 1 inch from the top. Cross out your address
if needed for safety.

3. Sign the cover sheet

4. Make 3 copies: (Take off this page first!)

 Yourself
 Linda
 And a ‘working copy’ for the Judge

5. File the original with the court clerk. Stamp copies with
the date filed.

6. Serve a copy on Linda's lawyer. Deliver

working copy to Judge
or (If local rules require working copies)
 Superior Court of Washington, County of Pierce
In re:
No. 21-3-04171-5
Petitioner/s (person/s who started this case):
Sealed Personal Health Care Records
Linda Chheng (Cover Sheet)
(SEALPHC)
And Respondent/s (other party/parties):
Clerk’s action required.
Micheal Scott Heinemann
For use in Family Law and Guardianship cases.

Sealed Personal Health Care Records

(Cover Sheet)
Use this form as a cover sheet to keep your personal health information private from the public. On the first page of
each document, write the word “SEALED” 1 inch from the top of the page.

Check the documents you are attaching to this cover sheet to be sealed:
[X] Health records of any kind (including correspondence) related to a person’s physical or
mental condition, or payment for health care.
[ ] Genetic test records for parentage.

Submitted by: [ ] Petitioner or his/her lawyer [X] Respondent or his/her lawyer

► Micheal Scott Heinemann

Sign here Print name (if lawyer, also provide WSBA #)

Important! The other person and the lawyers in your case can see your sealed documents. If you need to keep
your address information private for safety reasons, you may cross out or delete your address information.

GR 22(b)(3), (g) Sealed Personal

Mandatory Form (05/2016) Health Care Records
FL All Family 012 p. 1 of __