Medical Records Please allow at least 10 working days for your record to be copied. There may be a fee for record copying. To request copies of your records, please fill out and return the Authorization to Release Patient Health Information form below. You will need to fill out the authorization completely. Please make sure that you provide us with the following information: - Unique patient identifiers (i.e. name, birth date, social security number)
- Address of provider authorized to make the disclosure (i.e. Overlake Internal Medicine Associates or a physician)
- Name of the person or organization to whom Overlake Internal Medicine Associates may release information
- Description of the specific information to be released
- Description of the purpose or need for information
- Signature of the individual (patient or legally authorized representative) and date
Please print out the form and drop off, fax or mail it to the address below: Overlake Internal Medicine Associates
Attention: Medical Records
1407 116th Ave NE, Suite 200
Bellevue, WA 98004-3819 Phone: (425) 974-7606
Fax: (425) 990-5245  OIMA - Release of Authorization Form
|
