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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 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

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) 729-1309
Fax: (541) 431-8265

 
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