Evergreen Treatment Services is committed to providing excellent customer service when responding to requests for medical records.
In order to protect our patient’s privacy and confidentiality under 42 CFR Part 2, please download the Release of Information (ROI) form below.
DOWNLOAD THE RELEASE OF INFORMATION FORM
Fax or mail the completed form to the applicable clinic for which you are requesting records.
1700 Airport Way South
Seattle, WA 98134-1618
South Sound Clinic
6700 Martin Way East – Suite 117
Olympia, WA 98516-5586
South King County Clinic
1412 SW 43rd Street – Suite 140
Renton, WA 98057-4801
Cost of Medical Record Copies
Records requested for continuation of care are released at no charge. Records requested for reasons OTHER than for continuation of care or follow-up care may be assessed a fee as follows:
- A charge of $1.12 for the first 30 pages and $.84 per page for additional pages
- Postage fees are charged for billable requests when records are mailed and $25.00 fee, if applicable.
Because there may be a cost associated with your request, we recommend that patients determine which records are most relevant. If a fee applies, records are released when payment is received.
To learn how medical and substance use-related information about you may be used and disclosed, and how you can get access to this information, download our Notice of Privacy Practices form.