Patient Identification:
SYS1001-PKT (08/26/20)
PeaceHealth
Packet for
Request for Copy of Protected Health Information
1 of 6
How can I get copies of my medical records?
You have three options:
1. Use My PeaceHealth
▪ Some records are available, free of charge, at
www.MyPeaceHealth.org including medications, test results,
procedures, etc.
▪ If you do not yet have a My PeaceHealth account, you will
need an activation code. To receive an activation code,
contact your provider’s office or visit
www.MyPeaceHealth.org and click “Sign Up Now.”
2. Submit the Request for Copy of Protected Health
Information form
▪ If the records you need are not available on My PeaceHealth,
you can request to receive or have copies of your medical
records routed to a provider or a facility for a fee. Federal
law permits PeaceHealth to assess patients a reasonable,
cost-based fee for copies of their records (see 45 CFR §
164.524(c)(4)).
▪ See the following pages for more details and the request form.
3. Provider request
▪ If a non-PeaceHealth provider needs copies of records for
your care, the provider’s office can request records, free of
charge, by faxing a request to 360-527-9383.
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If the record is
currently…
and you receive it…
the fee is…
Electronic
Electronic
$6.50 fee + tax
Paper and Electronic
Electronic
$6.50 fee + tax
Paper and Electronic
Paper
$0.10 per page +
postage + tax
Paper
Electronic
$0.08 per page +
postage + sales tax
Questions? We’re here to help.
▪ Call 1-844-962-2090. Our Customer Service team is available
daily from 7 a.m. – 5:30 p.m. (PT).
▪ Email Releaseoflnfo@peacehealth.org.
▪ Visit www.peacehealth.org/medical-records.
MRO is the company that handles release of medical
records for PeaceHealth. As their partner for Release of
Information (ROI), it is our pleasure to serve you!
Thank you for choosing PeaceHealth. We are truly honored to be
your trusted healthcare provider.
SYS1001-PKT (8/26/20) Packet for Request of Copy of Protected Health Information P 2 of 6
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Request for Copy of Protected Health Information
You have a right under federal law to request a copy of
your health information.
How to request a copy of your health information:
1. Complete the Request for Copy of Protected Health
Information form.
To prevent possible delays in processing your request, please
carefully complete the form including:
o Your complete address and phone number in case we
need to contact you about your request.
o The date by which you need the records in the section
“Date records needed”. For urgent requests, please call
1-844-962-2090 or 360-729-1300.
o If you are a parent, guardian or personal representative,
please include your relationship to the patient in the
section “Relationship to Patient” and provide the required
documentation.
o Please clearly state where and how you want the records
to be delivered.
2. Return the request form using one of these methods:
o Email: ReleaseofInfo@peacehealth.org
o Fax: 360-527-9383 (If you are completing this request
at a PeaceHealth facility, you may ask a caregiver to fax
the form on your behalf.)
o Mail: PeaceHealth, HIM Department, ROI Services
1115 SE 164
th
Avenue, Dept.336
Vancouver, WA 98683
What to expect after you have submitted a request form:
• Your request will be processed within 15 business days once it
is received by the Health Information Management, Release of
Information department in Vancouver, WA. An invoice then
will be mailed to you (if there are charges).
• After payment has been received, the records will be delivered
in 5-7 business days, depending on the type of records and
the dates of service requested.
• If we are unable to process your request within 15 business
days, we will contact you to let you know the reason for the
delay and the anticipated processing date.
SYS1001-PKT (8/26/20) Packet for Request of Copy of Protected Health Information P 3 of 6
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Receiving your records:
• You may choose to receive your health information by paper,
electronically on a CD or via encrypted e-mail.
• PeaceHealth uses an e-mail encryption system to protect
confidential e-mail messages. If you choose to receive your
health information via encrypted e-mail, you will receive a
notification e-mail containing a link to access the full message
on our Secure E-mail Server. Directions will be provided in
the email for you to create a user account to receive your
information.
• Please note, unencrypted e-mail transmitted via the internet
has a risk of being intercepted by unauthorized individuals.
• After 15 business days, if you have not received your records
or been contacted, please check your email spam/junk folder.
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SYS1001-PKT (8/26/20) Packet for Request of Copy of Protected Health Information P 4 of 6
Request for Copy of Protected Health Information
Note: Most requests are sent within 15 business days.
To avoid delays, please print clearly and sign. (* = REQUIRED FIELDS)
*Patient Name: Last
*First MI ________
*Street Address
*City, State, Zip
Daytime Phone Evening Phone
*Date of Birth _______________
*Date Records Needed: ____________________
*WHAT FACILITY’S RECORDS ARE NEEDED? (check all that apply)
Hospital
PHMG
❑ Riverbend Hospital
❑ Clinic
❑ University District
❑ Clinic
❑ Cottage Grove Hosp
❑ Clinic
❑ Peace Harbor Hosp
❑ Clinic
❑ Southwest Hospital
❑ Clinic
❑ St John Hospital
❑ Clinic
❑ St Joseph
❑ Clinic
❑ Peace Island Hosp
❑ Clinic
❑ United General
❑ Clinic
❑ Ketchikan Hosp
❑ Clinic
Other Location: _____________________________________
*SEND RECORDS TO (RECIPIENT):
❑ Send to patient address above OR
❑ Facility Name: _________________________________
Street Address: ________________________________
City/State/Zip: _________________________________
SYS1001-PKT (8/26/20) Packet for Request of Copy of Protected Health Information P 5 of 6  ROI Authorization
*HOW TO SEND RECORDS:
❑ Mail to Recipient Address
❑ Fax to number: ________________________________
❑ Email to: _____________________________________
❑ Other delivery method (describe): _________________
_____________________________________________
*VISIT DATE RANGE NEEDED (SELECT ONE):
❑ Specific: (from) ____________ (to) ___________________
❑ One-year history ❑ Other: _______________________
*INFORMATION NEEDED:
❑ Provider documentation, medication list and diagnostic information:
Lab, X-ray, EKG (these are the most commonly requested items)
❑ Imaging Films ❑ Billing Records
❑ Other (specify): ___________________________________
Acknowledgements:
1. I understand that I may be charged a reasonable, cost-based
fee that covers the cost of copying, including supplies, labor,
and postage.
2. I understand that the information in my medical record may
include information relating to treatment of drug or alcohol
abuse, mental health, genetic information, sexually
transmitted disease, acquired immunodeficiency syndrome
(AIDS), AIDS related complex (ARC) and/or human
immunodeficiency virus (HIV).
3. I understand I must provide legal documentation if I am the
guardian or Medical Power of Attorney.
*Requester: _______________________(print
Signature: ______ *Date: _______
Relationship to Patient: ❑ Patient (self) ❑ Parent/*legal guardian
❑ *DPOA ❑ Other: __________
* Please attach proof of guardianship/DPOA (medical power of
attorney) with this request.
OPTIONS FOR RETURNING THIS COMPLETED FORM:
Fax: 360-527-9383 Email: releaseofinfo@peacehealth.org
Mail to: PeaceHealth, ATTN: HIM ROI; 1115 164
th
Ave, Dept 336,
Vancouver, WA 98683
Questions? Call 1-844-962-2090
SYS1001-PKT (8/26/20) Packet for Request of Copy of Protected Health Information P 6 of 6  ROI Authorization