Request Your Medical Records

For Your Provider's Use

If the medical records are being sent directly to a health care provider, we will accommodate your needs and send the records out, free of charge.

Just have your provider's office fax us a cover sheet with their letterhead requesting what they need for your appointment.

• Fax to 425.899.1933 (for EvergreenHealth medical records)
• Fax to 425.899.1918 (for EvergreenHealth Primary Care medical records)

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For Your Personal Use

To request a copy of your medical records for personal use, download and complete this form.

Make a photocopy of a government-issued photo ID card, such as a driver’s license.

Send the completed form, along with the photocopy of the ID card, to the Medical Records department by one of the following methods:

• Fax to 425.899.1933 (for EvergreenHealth medical records)
• Fax to 425.899.1918 (for EvergreenHealth Primary Care medical records)
• Mail to EvergreenHealth, Health Information Management MS-49, 12040 NE 128th Street, Kirkland, WA 98034
• Deliver in person to the Health Information Management (Medical Records) office, Room Red-B-514 at EvergreenHealth Medical Center (click for directions) during business hours Mon-Fri, 8am-5pm.

If you have questions about your medical record request, please contact us at 425.899.1920 during business hours Mon-Fri, 8am to 5pm.

Cost of Medical Record Copies

There is no charge for medical records to be sent directly to a health care provider.

Patient access charges are as follows:

• First 10 pages are provided at no charge
• Records stored in electronic record system:  $6.50
• Records stored in paper-chart format:
  • $0.34 per page for pages 11-30
  • $0.06 per page for pages 31-200
  • $0.03 per page for pages 200 and above
• Sales tax and shipping fees, if applicable

Patients are expected to supply payment at the time of processing for any bill due. Payment options include credit/debit card or checks; cash or money orders. You will be billed by CIOX Health, which provides the copying and mailing service.

If you are requesting your medical record for any other purpose, please call 425.899.1920 to get an estimate of the charges.

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Amendment Request to Your Medical Records

If you wish to submit an amendment request to your medical record, please download and complete this form.

Send the completed form to the Health Information Management (Medical Records) department by one of the following methods:

• Fax to 425.899.2064 (for EvergreenHealth medical records)
• Mail to EvergreenHealth, Health Information Management MS-49, 12040 NE 128th Street, Kirkland, WA 98034

If you have questions about the process for requesting changes to your medical record, please contact us at 425.899.1930 during business hours Mon-Fri, 8am to 5pm.