NEW Medical Records Request Form

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.

Email

example@example.com

Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

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 Due By

Reminder: this is not guaranteed

Work Order

.

Is this a Notice of Intent or Subpoena?

Notice of Intent or similar - do not process at this timeSubpoena - This submission is to be processed in 7-14 business daysN/A or Authorization Signed - This submission is to be processed in 7-14 business daysOther/Unsure

Time Period

All records on fileRecords from a period of time (please specify)

Any additional notes about this request?

Type

Medical RecordsBilling RecordsImaging records*Other (Please specify)

*If we have the requested imaging records, we will need to mail them to you. Please provide your mailing address below.

Preferred Delivery Method

FaxEmailOther (please specify)

Preferred Delivery Method

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.

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

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

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