Authorized Release Form (REQUEST)
Authorization for Kitsap OBGYN, PLLC to request and receive your records from another provider.
Authorized Release Form (RELEASE)
Authorization for Kitsap OBGYN, PLLC to send your records to another provider.
Effective 9/1/2020: due to the time and medical expertise involved, Kitsap OBGYN, PLLC will charge a nominal fee for the completion of any forms (such as FMLA, disability, etc.). This will be charged based on the length of the form and collected prior to releasing the form. Please allow 7 business days to complete your form and we ask that you plan accordingly. It will be your responsibility to complete your portion of the form and return it to the appropriate institution.