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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.
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* Indicates required question
Email
*
Your email
Your Name
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Your answer
Your Phone Number
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Your answer
Patient Name
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Your answer
Purpose of Disclosure
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Self
Insurance
Attorney
Disability
Physician
Other (please give detail in comment section at bottom)
Patient Birth Date
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MM
/
DD
/
YYYY
Patient Last 4 Digits SSN
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Your answer
Patient Address
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Your answer
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)
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Your answer
Which records are you requesting?
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Pertinent Health Record (Includes all reports and test results)
Discharge Summary
Operation Report
History & Physical
Consultation Report
ER Record
Lab Results
Pathology Report
Pathology Slides
Radiology CD/Films
Radiology Reports
Clinic or Center Visits
Outpatient Rehab (PT-OT-ST)
Facesheet
Required
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:
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My health record(s) will not be released or obtained unless permission is granted by my signature/agreement on this authorization
Required
Comments: (Please share any additional information that is relevant to helping Medical Records fulfill your request.)
Your answer
A copy of your responses will be emailed to the address you provided.
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