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.
Email address *
Your Name *
Your Phone Number *
Patient Name *
Purpose of Disclosure *
Patient Birth Date *
Patient Last 4 Digits SSN *
Patient Address *
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? *
Sensitive Information to be disclosed (if you would like to include this information do not check any of the options)
I understand that: *
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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