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

Mail Your Payment

If paying by check,
please mail to:
Olympia Obstetrics & Gynecology, PLLC
PO Box 431
Sequim, WA 98382

Request Medical Records

Submit Request

Contact email for billing and other questions

management@olympiaob.com

Request Your Medical Records

Please Complete the Form Below

Click the Print button after completing the form to print the page, and then please send via postal mail to:

Olympia Obstetrics & Gynecology, PLLC
PO Box 431
Sequim, WA 98382

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

 

    Patient Contact Information

    Enter any previous names that appear on your medical records

    Enter a Phone Number

    Medical Disclosures

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

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

    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:

    Reason(s) for this request:

    Please specify

    Disclosure Release Authorization

    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:

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    Printed name (if signed on behalf of the patient)

    Relationship to patient

    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 July 26, 2024 at 11:50 pm.

    Print this Form