Medical Records

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Authorization to Release Patient Information

IMPORTANT: Please be aware that not all personal emails are secured. For this reason, due to Federal HIPAA* regulations please do not include personal health information in your correspondence.

Authorization to Release Patient Information

To Request Copies of Your Record for Your Personal Use

Please fax your completed form to (206) 621-4235, or mail your form to:

HIM ROI Dept.

1200 12th Ave S

Seattle WA 98144.

There will be a fee associated with this request.

To Request Copies of Your Records be Sent to a Non-Pacific Medical Centers Provider

Please fax your completed form to (206) 621-4235, or mail your form to:

HIM ROI Dept.

1200 12th Ave S

Seattle WA 98144.

No fee charged.

To Request Copies of Your Records be Sent to Pacific Medical Centers from a Non- Pacific Medical Centers Provider

Please contact the non-Pacific Medical Centers provider and make your request directly to the provider.

If you have any other questions or concerns, you can contact us at (206) 621-4150.You can also email us; please include your name, a contact number, the dates you were seen (as best as you are able) and your date of birth.

*Health Insurance Portability and Accountability Act (HIPAA) protects the security and privacy of health data.