Obtaining Your Medical Records

Welcome to our Release of Information of page. We have made obtaining your medical records as easy as downloading the sample form shown below in a Word format, filling it out, and faxing it to the number on the top of the page.

On the line that says The Following Information, examples, if you were HIV or Hep C positive, you would want to request lab reports, chart notes, and treatment courses. If it were chronic pain due to surgery or an injury, you would want to write in, x-ray reports, MRI reports, and surgical reports. You could also write, all diagnostic-imaging reports. Generally, requesting the last 15 pages of your medical records should be enough to support a diagnosis of a physically qualifying condition.

In the event you are faxing us records already in your possession, please do not fax us more than 10 pages. If we need more, we will let you know.

Call us at 206-683-5702 if you have any questions. If in doubt, please call.

SAMPLE FORM - Click here for a Printer Friendly Version

Please make sure and sign the form, we cannot process it without a signature.

PATIENT’S NAME: ________________________________
BIRTH DATE:  ____________________________________
ADDRESS: ______________________________________
________________________________________________

MEDICAL CONDITION RECORDS ARE BEING REQUESTED FOR: ___________________________________

I HEREBY REQUEST AND AUTHORIZE:
_________________________________
Name of Medical Facility
_________________________________
Attending Doctor
_________________________________
Address
_________________________________
City, State, Zip Code
_________________________________
Phone Number
_________________________________
Fax Number
_________________________________
Email or Web Site

THE FOLLOWING INFORMATION: _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
FOR THE PURPOSE OF: MEDICAL TREATMENT AND EVALUATION


I UNDERSTAND that my records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as described above.

I UNDERSTAND that my express consent is required to release my health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. If I have been tested, diagnosed, or treated for HIV (AIDS virus), sexually transmitted disease, psychiatric disorders/mental health, or drug/alcohol use, the above mentioned entity is specifically authorized to release all health care information relating to such diagnosis, testing, or treatment.

I FURTHER ACKNOWLEDGE that the use of this information was explained to me and is given voluntarily by me and of my own free will. I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing to the entity requesting the information. I understand the revocation will not apply to information that has already been released and/or received in response to this authorization.

I UNDERSTAND that I can refuse to sign this authorization. I need not sign this form in order to receive services. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. A photocopy of this authorization shall be considered as effective and valid as the original.

______________________	_____________________
Patient Signature Date	Patient Printed Name

Click here for a Printer Friendly Word Document