Requests Will be Responded to Within 7 days
Office Releasing Records:
Dr.Trina Seligman
8201 164th St, Suite 200, Redmond, WA 98052
Ph: 425-999-4503 Fax: 425-646-4770
Your records will be sent to the email associated with your Patient Fusion account.
I understand that:
This authorization will expire 90 days from the date signed below unless another date is provided here:
Your signature is required to complete this document and initiate records transfer. If you have questions or concerns with any policy or part of this document please contact our office by email at staff@eimed.com.
My typed signature below is an indication that I authorize the transfer of records as indicated and have reviewed and agree with all policies presented.
Print this form if you require a copy for your personal records.
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