This form is only for Woodinville Pediatrics to request your child’s medical records from the previous provider. It is not for requesting records from Woodinville Pediatrics. You will receive an emailed copy of this form. We will fax the request to your child’s previous provider, so please make sure the fax number is accurate.
You must submit one form for each child.
We must have appropriate signature(s).
Signature of Patient (18 years or older) or Legally Responsible Party (Parent or Guardian)
Signature of Minor Patient (Ages 13-17) Required for Certain Records: a minor patient’s signature is required to release the following information: 1) Information related to reproductive care such as birth control, pregnancy-related services (all ages) 2) Sexually Transmitted Diseases, including HIV/AIDS (age 14 and older); 3) Substance abuse and mental health treatment (age 13 and older).
