Renton & Tacoma

Medical Records Request

To Obtain A Copy Of Your Medical Records

Please complete and sign these request forms, following the instructions below:

1. Records can be faxed, mailed, or picked up at the clinic. In the “To:” section of the Medical Release form, tell us to whom and how/where the records are to be released. Examples of this section:

      • To: Dr. Smith at Fax #: 555-555-5555
      • To: Dr. Washington at 1111 W 5th St. Somewhere WA 55555
      • To: Myself-Pick up at Renton Clinic

2. Give a current phone number in case there is a question about the request.

3. Copy of ID needs to be included with the record release forms.

4. The release & ID can be dropped off at the clinic, faxed to 509-575-0477, mailed to 106 East E Street Yakima, WA 98901 or sent through the form form below:
 

Your Name (required)

Your Phone (required)

Your Email (required)

Mailing Address in USA, Canada or Mexico:

City, State, Postal Code:

Your Message

Attach signed request form & copy of ID here:

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