Medical Records Request 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.

Seattle and Lynnwood are our only locations of Seattle Spine and Sports Medicine.  Our previous locations are now COAST Injury Medicine.  If you would like their records, please reach out to them.

If you need to request records from our Seattle and/or Lynnwood clinics, please uncheck 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. 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.

Seattle and Lynnwood are our only locations of Seattle Spine and Sports Medicine. Our previous locations are now COAST Injury Medicine. If you would like their records, please reach out to them.

Due to the administrative staff time and resources spent on processing and fulfilling medical records requests, we charge a flat fee of $50.00 (including sales tax). Once payment is received, your request will be processed.

Accepted payment methods:

• Online 
  • You may pay online at the bottom of this form.
• Checks 
  • Complete this form, but do not enter payment information at the bottom if you are paying by check.
  • Please make checks payable to: Seattle Spine and Sports Medicine.
  • You will need to include the Patient Name in the memo field or otherwise include it with your check. 
  • If you are tax exempt, our records fee before sales tax is $45.35. For all other payers, the fee is $50.
  • Mail checks to: 

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.

If you no longer wish to submit a records request, you may exit this page. 

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. 

For ONLY Billing Requests:

Please bypass the payment option and submit your request without prepaying.  We do not charge a fee for billing only records.

For ONLY Balance Verification Requests:

Please email the form to our Billing Department at billing@seattlespine.com.  No submission required.

For any Billing and Medical Requests:

Prepayment may still be required before processing your request fully.

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:

• Provide and coordinate treatment among health care providers who may be involved in my care.
• Obtain payment for my health care services from third-party payers and/or my legal representative (i.e. my attorney), as applicable.
• Conduct normal health care operations.

I understand that:

• This authorization, unless expressly limited by me in writing, will extend to all aspects of treatment, including testing and/or treatment for sexually transmitted diseases, AIDS, or HIV Infection, alcohol and/or drug abuse, and mental health conditions.
• This authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization.
• I am not required to sign this authorization in order to receive treatment at Seattle Spine & Sports Medicine, except in limited circumstances , such as research-related treatment or treatment that is solely for the purposes of disclosing health information to a third party.
• Any disclosure of information carries with it the potential for an unauthorized re-disclosure and may not be protected by federal or state confidentiality laws.

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.