Medical Records Request | Tri-City Orthopaedics in Kennewick

Authorization to Disclose Health Information Medical Records Release Request

An outside third party processes all of our medical record requests. It may take up to 14 business days to process your request.

Patient Information

Who is making the request?(Required)

I am either the patient or the patient's legal guardian filling out this form.

I am an authorized third party requesting these records. (NOTE: We must have a signed release form to process these requests)

Patient Name(Required)

Previous Name (if applicable)

Date of Birth(Required)

Phone(Required)

Do you have an email address?(Required)

Yes

No

Email Address(Required)

Enter Email Confirm Email

Street Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Record Request Information

Recipient:(Required)

Release to Patient

Release to:

Company Name(Required)

Company Contact

Phone Number(Required)

Fax Number(Required)

Email

Street Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Method of Delivery(Required)

NOTE: If radiology images are requested, a CD with those images must be mailed out.

Electronic Delivery

Paper Copies (additional fees may apply)

Date of Service(Required)

Last 2-years only

Only the following dates:

From this date(Required)

Through this date(Required)

Records to be Released(Required)

NOTE: We do not release other facilities' records, only Tri-City Orthopaedics.

Pertinent Package (History & Physical, Operative Report, Radiology Report, Clinic Visit)

Itemized Billing

Radiology Image(s) (CD to be mailed, please allow 3 additional business days to process)

Therapy

Other

Please specify(Required)

Purpose of Disclosure(Required)

Personal Use

Continuation of Care/Treatment

Legal/Injury

Other

Please specify(Required)

I Consent to the Following:(Required)

I understand that this authorization is good for this request only. Any other requests for medical records will require another form to be submitted.

Printed Name of Patient or Legally Authorized Representative(Required)

Date

Signature of Patient or Legally Authorized Representative(Required)

The signature below has been signed electronically

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