Medical Records Authorization for Washington

Please submit your forms by fax

We're asking for your help to reduce the amount of paper requests we receive. Please refrain from submitting your forms by mail. Instead, please fax them to the contacts listed below. Thank you.

Providence provides access to medical records from our hospitals and other medical facilities to patients and their authorized representatives. The following forms are intended for patients who received care at a Washington clinic or the following hospitals:

  • Providence Mount Carmel Hospital
  • Providence Centralia Hospital
  • Providence St. Peter Hospital
  • Providence St. Mary Medical Center
  • Providence Holy Family Hospital
  • Providence St. Luke's Rehabilitation Medical Center

Release of Information Authorization Forms

Authorization to Use, Disclose and Release Protected Health Information
Complete this form to authorize Providence 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 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 and business associates.

Formularios para autorización para liberar información de salud


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

Hospital Requests

Oregon Central
PO Box 4950
Portland, OR 97208
Phone: 503-215-7423
Fax: 503-215-0405

Clinic Records

Phone: 1-800-991-0936
Fax: 920-406-3763

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.


For credit card payments, you can pay online using information from your invoice or by phone: toll free 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:

Central Release of Information
P.O. Box 4950 Portland, OR 97208

Language Services

Providence provides free language services to people whose primary language is not English.

Providence Outpatient Services

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


Providence Health Plan offers online management of health and medical care to members through myProvidence. Learn more about myProvidence.


MyChart is a free service available to patients of many Providence Medical Group clinics which gives you online access to your health record. You can view test results, messages from your doctor and your medical information. You can even schedule your next appointment online.