Mercer Island Pediatrics

Records release, and authorization forms for MIP should be submitted via the Family Portal here. 

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Forms requiring completion by one of our providers, please note the following:

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We charge $20.00 per patient, per form.
Turnaround time for form completion is 24-48 hours.
If the form is needed same day, the charge is $40.00. Please note, all urgent forms need to be submitted by Noon or they will not be done same day. 
Payment is due at the time of the request, and are not billed to insurance. Forms must be submitted through the family portal.
If you wish to have any forms mailed back to you, please provide a self-addressed, stamped envelope.

Please complete the patient/history portion of forms prior to exam appointment - doctors are unable to complete and sign until you have done so.