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Florence, OR Locations

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

PeaceHealth Medical Group Peace Harbor
380 Ninth Street
Florence, OR 97439
Phone: (541) 902-1617
Fax: (541) 902-1609

390 Ninth Street
Florence, OR 97439
Phone: (541) 902-6145
Fax: (541) 902-1466