Health Information Management/Medical Records

To request a copy of your medical records, please select the appropriate form below. Print, complete, sign, date and return the form to contact information listed. Call if you need more assistance.  

• ​ROI Contact Information
• If you are mailing a request, 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.

​Request my medical records

• English: Request for Access to or Copies Form
• Spanish: Request for Access to or Copies Form - Spanish
• Visually Impaired: Request for Access to or Copies 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.

• English:  Request Restriction of Protected Health Information
• Spanish: Request Restriction of Protected Health Information - Spanish
• Visually Impaired: Request Restriction of Protected Health Information - Visually Impaired

Request for Amendment of Protected Health Information

• English: Request for Amendment of Protected Health Information
• Spanish: Request for Amendment of Protected Health Information - Spanish
• Visually Impaired: Request for Amendment of Protected Health Information - Visually Impaired

Additional questions?

If you have questions about obtaining copies of medical records,  please call our customer service center at 360.729.1300 or email us at releaseofinfo@peacehealth.org.