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 (must have consent/ROI signed by patient). 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. 
  • 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.