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

Browse Files

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
Should be Empty: