Medical Records Request

Today's Date

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Social Security Number*
Dates of Service Requested
From*

MonthDayYear
To*

MonthDayYear
Requesting facility name
If you are requesting medical records on behalf of a patient, please attach a medical records release form including the patient's name, signature and date

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Cancelof
I am requesting that the medical records requested be sent to the email address below. I acknowledge that the requested medical records will not be faxed or mailed. I understand that processing will begin only upon receipt of payment in the form of cash or check made to Urologic Surgeons of Washington.
E-mail Address of Recipient*
example@example.com
Your Signature*

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