Olympia Obstetrics Gynecology White

Medical Records for services prior to 6-01-2023

Olympia Ob Gyn ceased to provide medical services as of 6-01-2023. To access historical patient medical records, please review the updated information below, effective 9-01-2024.

PATIENTS: Request records prior to 6-1-2023 from various third parties, as well as OOG, as noted below. A copy of your picture identification – drivers license, state or federal identification – is required for any entity to process records request. Note if you are being seen by Providence and you also had services at OOG between 6-1-2020 and 5-31-2023, and you did not opt out of sharing records, ask Providence to activate your history that was brought over during employment transition.

PROVIDERS: Please direct patients to request their own records by referring them to our websitewww.olympiaob.com. Please ensure they have the correct mailing address for your practice. We will not be responding to providers. The practice stopped providing medical services as of 5-31-2023 and is dissolving as of 9-30-2024.

Contact Info for Dates of Service prior to June 1, 2023



Cellnetix Reports

Pap, HPV and other pathology reports

Email:
information@cellnetix.com

Phone:
206 576-6050

Mail:
12501 E Marginal Way S, Suite 200
Tukwila, WA 98168

Ask for all reports on file unless you know a specific date

PRINT Release Form

Include Patient Photo ID for processing



Radia/South Sound Radiology

(Located on Ensign Rd)

Mammogram, ob ultrasounds, and other diagnostic test reports

Email:
ssrrecords@radiax.com

Phone:
360 493-4646

Fax:
360 493-4614

Address:
3417 Ensign Rd NE,
Olympia, WA 98506-5075

Ask for all reports on file unless you know a specific date

PRINT Release Form

Include Patient Photo ID for processing



TRA/Northwest Radiology

(Located on Lilly Rd)

Diagnostic & OB ultrasounds

Email:
northwest-las@vrcofnv.com

Phone:
253 761-4200 Opt 4

Mail:
TRA Medical Record Dept
PO Box 1535
Tacoma, WA 98401

Ask for all reports on file unless you know a specific date

PRINT Release Form

Include Patient Photo ID for processing



Providence St Peter Hospital Records

Delivery & Surgical Reports

Email:
phssw.medrec@providence.org

Phone:
360 491-9480

Fax:
360- 493-4543

Mail:
Prov SPH HIMMSLLH18
413 Lilly Rd NE
Olympia, WA 98506

Ask for all reports on file unless you know specific type of report and/or date ranges



Olympia Ob Gyn

Clinic office notes and anything not covered by third parties above.

Email: medicalrecords@olympiaob.com

To send your request so it is HIPAA secure, in the Subject line, please type: #encrypt# and nothing else.

PRINT Release Form BELOW

Request Your Medical Records

Please Complete the Form Below

Click the Print button after completing the form to print the page.

Send encrypted via email to medicalrecords@olympiaob.com.
To encrypt type #encrypt# in the subject line and nothing else.

*Requests may take up to 15 business days.*
Patient photo identification is required to process this request.

Patient Contact Information

First Name*

Last Name*

Date of Birth*

Any Previous Names

Enter any previous names that appear on your medical records

Email*

Enter a Valid Email

Telephone*

Enter a Phone Number

Medical Disclosures

Olympia Obstetrics & Gynecology may disclose the following health care information (check all that apply):

All healthcare information in my medical record excluding third party records at Cellnetix, Radia, TRA and Providence SPH.

Health care information in my medical record relating to the following treatment or condition:

Health care information in my medical record for the date(s):

*

Other (e.g., X-rays, bills)—specify date(s):

*

Olympia Obstetrics & Gynecology may disclose health care information regarding testing, diagnosis, and treatment for (check all that apply):

• HIV/AIDS

• Mental Health or Illness

• Reproductive Care (minors only)

• Sexually Transmitted Diseases

• Drug and/or Alcohol Abuse

Minors – a minor patient’s signature is required in order to disclose information related to reproductive care, sexually transmitted diseases (if age 14 and older), HIV/AIDS (if age 14 and older), drug and/or alcohol abuse (if age 13 and older), and mental health or illness (if age 13 and older).

Medical Records Recipient

Please send this health care information to:

Recipient Name*

Recipient Title*

Recipient Mailing Address*

Recipient City*

Recipient State*

Recipient Zip*

Reason(s) for this request:

*

Please specify

Disclosure Release Authorization

I understand that once my health care information is disclosed, the person or organization that receives it may re-disclose it and that privacy laws may no longer protect it.

Authorized Signatures

Patient or legally authorized individual signature

Please sign your name in the box below using your finger/stylus or a computer mouse.

*

I am making this records request on behalf of:

MyselfSomeone elseMinor

Please make a selection

Printed name (if signed on behalf of the patient)

Relationship to patient

*

ParentLegal guardianPersonal representative

Minor patient’s signature, if applicable

Please have the minor sign their name in the box below using their finger/stylus or a computer mouse.

* Requests May Take Up to 15 Business Days *

This form submission will be date/time stamped at December 21, 2024 at 4:52 am.

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