NEW Medical Records Request Form

Medical Records Request Form
BEFORE YOU PROCEED

Please note: This form is only for patient's seen at Seattle Spine & Sports Medicine locations in Seattle or Lynnwood.

Clinics in Renton, Puyallup, Lacey, and Everett are now operating under Coast Injury Medicine. While we have shared a practice name, we do not have access to their records.

Records requests will be processed in the order received. Please allow 7-14 business days for our staff to get your records to you.

Balance Verifications can be uploaded along with your request, or emailed directly to billing@seattlespine.com.

General records inquiries or staus updates on submitted requests can be done over the phone at 206-861-8200 or by emailing medrecs@seattlespine.com.
a former/current patient of Seattle Spine & Sports Medicine/Brain Injury Medicine of Seattle.from an attorney's office, records retrieval service, government agency, or insurance company.from a medical provider's office.Seattle Spine Staff (Internal Use Only)Other
Please read each question carefully as it can affect the submission requirements and may cause delay.

Former/Current Patient Submission Page

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Attorney's Office, Records Retrieval Service, Government Agency, or Insurance Company Submission Page

If this does not apply to you, please refresh or go back to restart
Medical Provider's Office Submission Page

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Seattle Spine Staff (Internal Use Only) Submission Page

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Other/Unknown

If this does not apply to you, please refresh this page to restart
Before we continue, we need a little more information from your office.
Who is requesting records?
.
Relationship to patient
Representing Attorney, Records Retrieval, spouse, etc.
Reason for request
Please provide a brief description of why you are submitting this request for patient records.
Please provide your contact information below in case we need to follow up with you about this request.
Who is the best contact regarding this request?
Contact Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
Records being requested
Records Due By

MonthDayYear
Reminder: this is not guaranteed
Work Order
.
All records on fileRecords from a period of time (please specify)
Any additional notes about this request?
Medical RecordsBilling RecordsOther
*Please be advised that our office does not maintain or store radiology imaging (such as X-rays, CT scans, MRIs, or ultrasounds).
FaxEmailOther (please specify)
FaxEmailMail (CD)Upload (Provide website below)
Mailing address is the same as aboveEmail address is the same as above
Email option is required in case documents are too large to fax.
Records recipient email is same as contact above
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
Signature

Clear
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.
Upload Signed Release

You may also upload any other documents applicable to this request
Cancelof
Should be Empty:

Medical Records Request Form

Former/Current Patient Submission Page

Attorney's Office, Records Retrieval Service, Government Agency, or Insurance Company Submission Page

Medical Provider's Office Submission Page

Seattle Spine Staff (Internal Use Only) Submission Page

Other/Unknown

Patient Information

Records being requested