Request for Olympia Medical Center Medical Records
DO NOT CLICK "REQUEST EDIT ACCESS". Completing this form is the Request for Access to medical records.
Authorization for disclosure of Protected Health Information (PHI). The information completed below will be stored securely and a notification will be sent to the Medical Records department. Medical Records will contact you if there are any questions and will notify you when your records are ready. Due to the large volume of requests, this process can take up to 30 days.
NOTE: If you have already completed a paper form with the Medical Records office, you do NOT need to complete this online form.
Your Phone Number
Purpose of Disclosure
Other (please give detail in comment section at bottom)
Patient Birth Date
Patient Last 4 Digits SSN
I hereby authorize Olympia Medical Center to release the following information to (Must include Name/Provider/Facility, phone, street address, city, state, zip and/or fax)
Which records are you requesting?
Pertinent Health Record (Includes all reports and test results)
History & Physical
Clinic or Center Visits
Outpatient Rehab (PT-OT-ST)
Sensitive Information to be disclosed (if you would like to include this information do not check any of the options)
I DO NOT want information about mental health released
I DO NOT want information about AIDS/HIV and related information released
I DO NOT want information about Alcohol and/or substance abuse released
I understand that:
My health record(s) will not be released or obtained unless permission is granted by my signature/agreement on this authorization
Comments: (Please share any additional information that is relevant to helping Medical Records fulfill your request.)
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Olympia Medical Center.