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:
  • 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.*

Send your completed request form to [email protected] or fax to 206-538-6301.

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Download Medical Release Form

For Check Payments

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

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 release

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

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

Anesis Spine & Pain Care

Providing multi-disciplinary care for those suffering from chronic pain.

Contact Us

Tel: 206-538-6300

Fax: 206-538-6301

Email: [email protected]

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