Please note: Record requests will be processed in the order received. Please allow approximately 2 weeks for our staff to get your records to you. If you do not receive your records in 2 weeks, feel free to reach out to us for a status update. See below for our contact information:
Unfortunately, we will not be able to process this request. The Renton, Puyallup, Lacey, and Everett clinics are separate entities from the Seattle and Lynnwood clinics and therefore do not share a medical records system, records custodian, or other staff members. Please contact the location you are requesting records from directly. You may visit our website, https://seattlespine.com/, for contact information for each clinic.
If you need to request records from our Seattle and/or Lynnwood clinics, please uncheck any other locations and proceed with this form.
IMPORTANT
If you are not sure which clinic you need records from, please note that you may still complete this form and submit payment (if applicable). However, if the records are from any location other than Seattle or Lynnwood, we will not be able to process your request and will refund your payment as soon as our staff verifies no records exist in our system.
The Renton, Puyallup, Lacey, and Everett clinics are separate entities from the Seattle and Lynnwood clinics and therefore do not share a medical records system, records custodian, or other staff members. Please contact the location you are requesting records from directly. You may visit our website, https://seattlespine.com/, for contact information for each clinic.
If you are not sure which clinic you need records from, please note that you may still complete this form. However, if the records are from any location other than Seattle or Lynnwood, we will not be able to process your request and will reach out to let you know as soon as our staff verifies no records exist in our system.
Due to the administrative staff time and resources spent on processing and fulfilling medical records requests, we charge a fee of $50.00 (including sales tax). Once payment is received, your request will be processed.
Accepted payment methods:
Seattle Spine and Sports Medicine 3213 Eastlake Ave E, Ste A Seattle, WA 98102
If you no longer wish to submit a records request, you may exit this page.
Please note, due to the administrative staff time and resources spent on processing and fulfilling medical records requests, most requests require payment of a fee of $50.00 (including sales tax). Please complete this form and our staff will reach out to you if payment will be required to fulfill your request.
Please provide your contact information below in case we need to follow up with you about this request.
Why do we ask for this information?
We require multiple pieces of personal information in order to verify your identity. This is to ensure your medical records are only released if you have provided your consent. This form is HIPAA compliant and your information will be used solely by our staff for the purpose of verifying your identity.
If we have the requested imaging records, we will need to mail them to you. Please provide your mailing address below.
My signature confirms that I have been informed that I have rights to privacy regarding my protected health information, and I have been given the opportunity to review this office’s Notice of Privacy Practice as required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
I understand that:
The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
If you are anyone other than the patient or a treating medical provider's office, please upload a completed release form signed by the patient or their legal guardian. You can find a release form here if you do not already have one.
Please click one of the PayPal options to complete payment and submit the form.