Request for Medical Records Request form - Providence Washington 2026

1. Click ‘Get Form’ to open the Request for Medical Records Request form in the editor.
2. Begin by entering your name and phone number in the designated fields at the top of the form. This identifies you as the requestor.
3. Fill in the patient’s name, date of birth, and social security number. Ensure accuracy to avoid processing delays.
4. Provide contact information for where the records should be sent, including address, city/state/zip, fax number, and phone number.
5. Select which specific medical records you are requesting by checking the appropriate boxes and providing relevant dates of service.
6. State the purpose of your request clearly in the provided section to ensure compliance with privacy regulations.
7. Sign and date the authorization section at the bottom of the form. If applicable, include details about a surrogate decision maker.

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