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: 

  • Fax it to the Release of Information contact number listed here.
  • If you are mailing a request, write "Attention Health Information Management - ROI" on the envelope and mail to: 
         PeaceHealth  
         Attention: Health Information Management- ROI
         1115 SE 164th Avenue, Dept. 336
         Vancouver, WA 98683 

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 or address

English

Request for Access to or
Copies Form

Authorization to Use and Disclose Health Information Form

Guide to Complete Form

Spanish

Request for Access to or
Copies Form - Spanish

Authorization to Use and Disclose Health Information - Spanish

Visually Impaired

Request for Access to or
Copies Form - Visually Impaired

Authorization to Use and Disclose Health Information Form - Visually Impaired

Additional Forms

Request Restriction of your Protected Health Information

To Request Restriction of your Protected Health Information, please choose the appropriate form.

Request for Amendment of Protected Health Information

Request for Alternate Communications of Protected Health Information

PHMG Family and Friends Information Form

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