Olympia Obstetrics Gynecology White

Legacy Company for services prior to 6-01-2023

Now operating as Providence Swedish Obstetrics & Gynecology, Olympia. For future appointments and continued care, please call 360 413-8413.

https://www.providence.org/ locations/wa/obstetrics-and-gynecology-olympia

For payments and medical records requests prior to 6-01-2023, please continue below on this website.

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

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Pay Your Bill Online

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Mail Your Payment

If paying by check,
please mail to:
Olympia Obstetrics & Gynecology, PLLC
PO Box 1008
Olympia, WA 98507-1008

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Request Medical Records

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Billing Questions and Insurance Updates

Please email billing@olympiaob.com

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Other Questions?

medicalrecords@olympiaob.com
management@olympiaob.com

Request Your Medical Records

Please Complete the Form Below

* Requests May Take Up to 15 Business Days and are Mail Dependent *

Patient Contact Information

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Date of Birth

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Medical Disclosures

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

All health care information in my medical record

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):

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

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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:

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Reason(s) for this request:

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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

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I am making this records request on behalf of:

MyselfSomeone elseMinor

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Printed name (if signed on behalf of the patient)

Relationship to patient

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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 and are Mail Dependent *

This form submission will be date/time stamped at May 10, 2024 at 8:54 am.

Olympia Obstetrics Gynecology White

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