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For Patients, Families & Visitors > Patient Services

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 record
to me

Send a copy of my record to
another address or person
English Request for Access to or Copies Form 

Authorization to Use and Disclose Form

Guide to Complete Form
Spanish Request for Access to or Copies Form - Spanish Authorization to Use and Disclose Form - Spanish
Visually Impaired Request for Access to or Copies Form  - Visually Impaired Authorization to Use and Disclose 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
HIM ROI Department
1115 SE 164th Avenue, Dept. 336
Vancouver, WA 98683 


Phone: (360) 729-1300
Fax: (360) 756-4871​
 

 

 

 

 

 

 

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