Central Hub

Request Medical Records

Authorize another practice to send your medical records to First Medical Associates.

Authorization to request healthcare information

Tell us which practice has your records, choose what to request, and sign below. Your authorization allows that practice to send your records to First Medical Associates.

Download fillable PDF

Fields marked * are required. Completed authorizations are sent to MedicalRecords@drsfirst.com.

1. Patient information

Patient full name *Date of birth *

2. Which practice should send your records to FMA?

I request and authorize the physician/practice below to release my healthcare information to First Medical Associates.

Practice / physician's name *

Practice phone (optional)Practice fax (optional)

Practice street address *

City *

State *ZIP code *

3. Information to request

This request and authorization applies to the following. Select at least one option. *

All healthcare informationHealthcare information relating to a specific treatment, condition or datesOther healthcare information

Additional permissions (optional)

These permissions are separate choices. Check only those you authorize.

I authorize the release of my STD, HIV/AIDS results, whether they are negative or positive, to the person/practice listed above.I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person/practice listed above.

STD definition from the original form

Definition: Sexually Transmitted Diseases (STD) as defined by law, RCW 70.24 et seq, including herpes, herpes simplex, human papillomavirus, wart, genital wart, condyloma, Chlamydia, nonspecific urethritis, syphilis, VDRL, lymphogranuloma venereum, HIV, AIDS & gonorrhea.

4. Sign your authorization

If younger than 18, parent/guardian must sign. This authorization expires one year after it is signed and may be revoked by patient at any time.

Electronic signature (full name) *I am signing as *

The signature date is recorded automatically when you submit.

By checking this box and typing my full name, I intend to electronically sign this authorization. I confirm that I am the patient or the patient's parent/legal guardian and authorize First Medical Associates to process this request. *

Please review your entries before submitting. Our records team reviews the authorization before requesting your records from the practice you listed. Privacy Policy