Medical Records Authorization for Washington
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.
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
- Autorización para usar o divulgar información médica protegida - hospital
- Autorización para usar o divulgar información médica protegida - clínica
- Solicitud del paciente para acceder al conjunto de registros designado - hospital
- Solicitud del paciente para acceder al conjunto de registros designado - clínica
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.
PO Box 4950
Portland, OR 97208
PO Box 1147
Everett, WA 98206
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.
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.
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
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.