206-538-6300 | Fax: 206-538-6301 | Email: Info@anesispain.com

Medical Records Release Form

Please note the following changes effective immediately:

  • All records requests that are sent to individuals other than a Primary Care Provider must have a signed release form from the patient.
  • Any records, regardless of date of service, requested by entities other than a provider (Patient, Housing Authority, Attorney, etc.) will be invoiced and payment must be received prior to releasing records.
  • A specialist requesting records will only be given a year’s worth free of charge. Any records dated prior to a year from the current date will be invoiced and sent to the patient and payment must be received prior to releasing records.
  • If there are certain dates/records you are requesting please let it be known on the Release of Information Form.
  • Fees are as followed *In accordance with WAC 246-08-400* and Washington State Labor and Industries Guidelines
  • We are the custodians of the medical records for Seattle Pain Centers. If you are a patient from SPC and you are requesting medical records, you have two options. One option is to sign a ROI and payment is required. The other option is to ask your primary care provider to request medical records and this is free of charge. We do not have the billing records for Seattle Pain Centers. 
  • Please allow 10 business days to process records once request/payment is received

*We accept Visa and MasterCard, Please call 206-538-6300 and choose the option for our billing department  to make a credit card payment over the phone.*

Please make checks payable to PAIN CARE PHYSICIANS and mail them to:

PAIN CARE PHYSICIANS

801 SW 16TH ST #121

RENTON, WA 98057

Please include a copy of this Invoice or reference this invoice when remitting payment for records

Hi Tech Fee Schedule(Records are burned to a Disc and MAILED):
$25.94-Copying & Producing Fees
+Tax

Paper Copy Fee Schedule(Faxed/printed):
$25.00-Clerk Fee
$1.12-Per page (1-30)
$0.84-Per page (31+)
+Tax

*Please note all Anesis Patients are able to view and print their records for free online via their Patient Portal.