ROI / Records Request

Release of Information / Records Request

Please complete & submit the following form including date & signature to be used by AceMed Seattle, PLLC to obtain medical records from other providers.
Last Name
First Name
Date of Birth
Medical Records are being requested from:
Clinic Name / Health System*
Ex.
Provider(s)*
Dr. Gregory House, MD
Street Address*
Ex. 308 Negra Arroyo Lane
City*
State*
Zip*
Phone*

Area CodePhone Number
Fax*
I authorize the above medical facility to release any and all medical information contained in mymedical records to Acemed Seattle.

I release Acemed Seattle and its staff from all legalresponsibilities or liabilities that may arise from the release of this information.

I understand that I may revoke this consent at any time, except when the action has been taken.

This request expires in one (1) year from the signed date below unless otherwise requested in writing before the setforth date.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Release of Information / Records Request