This form is used to request medical records from other clinics and providers, including chart notes, lab results, imaging reports, procedure notes, etc. Once you submit it, we fax it directly to the named entitiy.

This form is required by Washington state. It must be submitted prior to the beginning of each visit by Medicaid patients. Visits, services, or procedures without a corresponding form will be billed directly to the patient at the full rate.

Sign up for our low cost monthly membership by submitting this form. Ensure you have fast access to your provider and care team for less than what it costs to get a cup of coffee once a week.