Medical Records Release Form
A medical records release form gives Anesis Spine & Pain Care clinic access to view our new patient’s medical history. This is necessary to give you the best care and advice for medical interventions
Please note the following changes effective immediately:
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All records requests that are sent to individuals other than a Primary Care Provider must have a signed release form from the patient.
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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.
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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.
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If there are certain dates/records you are requesting please let it be known on the Release of Information Form.
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Fees are as followed *In accordance with WAC 246-08-400* and Washington State Labor and Industries Guidelines
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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.*
Send your completed request form to [email protected] or fax to 206-538-6301.
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Please make checks payable to PAIN CARE PHYSICIANS and mail them to:
Hi Tech Fee Schedule [Email, fax, or flash drive]:
$6.50-Copying & Producing Fees + 10.1% Tax = Total Balance Due: $7.16
Paper Copy Fee Schedule:
$26.00-Clerk Fee
$1.17-Per page (1-30)
$0.88-Per page (31+)
+ Additional 10.1% Tax
*** Shipping fees are included for both Hi Tech and Paper Copy