For copies of your IPC Medical Record

For OAG Interventional Pain Clinic Patients
If you were a patient of the OAG Interventional Pain Clinic and would like a copy of your IPC medical records for yourself or to send to another person or company, please send us a letter and include the following information:

  1. Patient’s full name
  2. Patient’s date of birth
  3. Date(s) of service or date range of the medical records you want
  4. How you would like your medical records sent:
    • by mail, please include the delivery address;
    • by fax, please include the fax number; or
    • by secure email, please clearly write the email address.
  5. The requesting person’s name, signature, and date
  6. The requesting person’s relation to the patient (e.g., self, parent, personal representative)
  7. If you are a personal representative signing the letter on behalf of the patient, please provide a description of your authority to act on behalf of the patient and a copy of official documentation granting this authority.

For Third Parties
If you are a third party (e.g., car insurance company, etc.) and are initiating a request for a patient’s IPC medical records, please download the Authorization Form below and have the patient complete it.

Authorization Form (PDF)

Where to Send Your Request
You may send us your letter or completed Authorization Form in one of the following manners:

By Mail:
P.O. Box 739
Enumclaw, WA 98022

By Fax: (206) 686-2840
By Email:

PLEASE NOTE: Before using email to communicate your request, you should understand that there are certain risks associated with the use of email. It may not be secure, which means your email could be intercepted and seen by others.

If you have questions about your request, please contact SIS NW at (206) 686-2821. Please contact SIS NW for information regarding fees associated with the release of requested medical records.

PLEASE NOTE: When requesting both your IPC medical and billing records, you will receive them separately.


Do not include personal health information in this email. Information sent via email should not be considered secure.