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For Patients, Families & Visitors

Patient Services

Health Information Management/Medical Records

 To request a copy of your medical records please select the appropriate form below. Print, complete, sign and date the form, then mail or fax it to the contact information listed below. If you are mailing a request, write "Attention Health Information Management- ROI" on the envelope.

Upon receipt of the completed form, we will either promptly process your request or contact you if further information is needed. If a fee is assessed for processing the requested records, you will be called in advance.

 

Send a copy of my medical records to me

Send a copy of my medical records to another person

English  Request for Access to or Copies 
of Form 		Authorization to Use and Disclose Health Information Form

Guide to Complete Form

 Spanish Request for Access to or
Copies Form - Spanish		 Authorization to Ues and Disclose Health Information Form - Spanish
Visually
Impaired  		Request for Access to or Copies  Form - Visually Impaired Authorization to Use and Disclose Health Information Form - Visually Impaired

 

 If you have questions about obtaining copies of medical records, the address, phone and fax numbers for the Release of Information staff are listed below.

Contact Information

Peace Harbor Medical Center
400 Ninth Street
Florence, OR 97439
Phone: (541) 902-6551
Fax: (541) 997-3163