Records Request

Requester Name

If "Other" relationship to Client, please describe.

Requester Email Address

Requester Phone Number

Client Name

Client Date of Birth

Client Phone Number

Client Email Address

Therapist seen at ITS

Approximate Date Range of when Client was seen at ITS

Please note that ITS retains records for 5 years following the final date of service, in accordance with WAC 246-809-035. Any records outside this limitation have been destroyed.

Recipient Name

If "Other" relationship to Client, please describe

Does ITS have a Release of Information (Authorization for Use and Disclosure of Protected Health Information, a.k.a ROI) for you on file? Any recipient of records other than the Client must have a ROI on file before records may be released. Parents/Guardians may receive records without a ROI IF the Client is under the age of 13.

Yes No

Records CANNOT be released until a signed ROI is on file. ROIs must be signed by the Client OR the Parent/Guardian IF the client is under the age of 13.

I am the Client I am the Parent/Guardian of the Client who is under the age of 13 I don't know

Have the Client call ITS at 253-460-7248 to find out.

If an ROI has not been completed, the Client may fill one out by printing and signing this PDF Authorization for Use and Disclosure of Protected Health Information - ROI, or calling ITS at 253-460-7248 and requesting the form be added to their Client Portal so it may be completed digitally. Hard copies may be scanned and emailed to hello@integratedtherapynw.com, faxed to 253-564-4409, or brought in person.

Start Date

If Specific Date Range

End Date

If Specific Date Range

Type of Records Requested

Psychiatric/Progress Notes

Attendance History

Diagnosis and Treatment Plan

Billing and Payment History

All

How would you like to receive records?

Encrypted Email - PDF file

Mail - Hard copy

Fax - Hard copy

Pick Up In-Person - Hard copy

Recipient Phone Number

Recipient Email Address

Recipient Fax Number

Recipient Physical Address

Please note there is a fee associated with Records Requests. If the Client is requesting their own records, there is a flat rate of $6.50.

If someone other than the Client is requesting records, charges are based on WAC 246-08-400: https://apps.leg.wa.gov/wac/default.aspx?cite=246-08-400

Fees must be paid before ITS may release the records.

Please also note that all records requests are prepared by the client's therapist. If the therapist is no longer with our office, the records request will be prepared by the therapist's supervisor or one of the owners.

Other Information / Questions:

Your information will be encrypted.

Records Request

Integrated Therapy Services NW