Medical Records Authorizations

Providence Health & Services provides access to medical records from our hospitals and other medical facilities in Oregon to patients and their authorized representatives.

Release of Information Authorization Forms

Authorization to Use, Disclose and Release Protected Health Information
Complete this form to authorize Providence Oregon to disclose a copy of your Protected Health Information to someone other than yourself. 

Patient Request to Access a Designated Record Set
Complete this form to receive a copy of your Protected Health Information.

Protected Health Information Restriction and Revocation Forms

Patient Request to Restrict a Designated Record Set
Complete this form to restrict or limit how Providence Health & Services uses your Protected Health Information, or to whom it is disclosed.

Patient Self Pay Restriction Request
Complete this form to request a restriction of disclosure to your health plan. Providence is required to agree to the restriction for which you, the patient, and/or the guarantor must pay in full and out-of-pocket at the time of visit.

Patient Request the Revocation of Restriction to Use or Disclose Protected Health Information
Complete this form to request to terminate or revoke restrictions currently in place for use or disclosure of your Protected Health Information.

Amendment Form

Request to Amend a Designated Record Set
Complete this form to request a correction to the patient's Protected Health Information which was originated or created by a physician.

Accounting of Disclosures Form

Accounting of Disclosures
Complete this request form for an accounting of disclosures of your Protected Health Information by Providence Health & Services and business associates.

Release of Information Authorization Forms – Spanish

Authorization to Use, Disclose and Release Protected Health Information

Patient Request to Access a Designated Record Set

Availability
Release of Information (ROI) service center is staffed 24/7 by trained ROI specialists. The ROI service center staff can answer questions related to the release of information throughout Providence Health & Services.

Questions pertaining to continuation of care will be answered 24/7. Other questions will be answered during regular business hours.

Where to submit forms
ROI receives requests via fax, USPS, FedEx, UPS, ProvSecure email or electronic submission.  If you wish to hand deliver your request, please drop it off at any Providence hospital’s Medical Records department or Providence Medical Group clinic during business hours.

Turnaround times
Requests are typically processed within five days of receiving the request, depending on requestor type. For example, routine continuation of care requests will be processed within 24 hours and urgent continuation of care requests will be processed within 20 minutes.

Fees
Patient copies on paper for personal use:
First 10 pages of each visit: free
Additional pages: $0.38 per page

Payment
For credit card payments, please phone toll free 1-855-234-2491 or locally in Portland and the surrounding area, 503-215-7423.  We accept all major credit cards.

If paying by check, please send payment to our Release of Information Service Center and Help Line.

Providence outpatient services
For records from outpatient Providence services such as rehabilitationhome health or hospice, please contact the program or clinic directly.

myProvidence
Providence offers online management of your health and medical care through myProvidence. myProvidence is available to Providence Health Plan members and at many Providence Medical Group clinics. Learn more about myProvidence.