Medical service provided by
Pain Care Physicians, PLLC
206-538-6300 | Fax: 206-538-6301 | Email: info@anesispain.com

Medical Records Release Form

Thank you for choosing Anesis Spine & Pain Care.

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
  • 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
Once your request is processed, we will send you an invoice. Please include a copy of the invoice when remitting payment. Once payment is received, records will be released.

Hi Tech Fee Schedule [Email, fax, CD, or flash drive]:
$6.50-Copying & Producing Fees + 10% TaxTotal Balance Due: $7.15

Paper Copy Fee Schedule:
$26.00-Clerk Fee
$1.17-Per page (1-30)
$0.88-Per page (31+)
+ Additional 10% Tax

*** Shipping fees are included for both Hi Tech and Paper Copy

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