Medical Records Authorization: St. Luke's Rehabilitation Medical Center

Release of Information Authorization Forms

This form is used to release patient medical information to the patient, parent/guardian or a third party.

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.

To request your patient medical record:

  1. Download and complete the form
  2. Print and sign the completed form
  3. Provide a copy of your ID with a signature for verification
  4. If you have any questions, call us at 509-473-6912
  5. If POA or Legal Guardian to said patient, please provide a copy of relevant paperwork
  6. Fax completed form to 509-897-8595

Fees

Fee schedule for electronic request of personal health information:

Item:  Price:
Labor Charge Small (0-100 pages) $9.28
Labor Charge Large (100+ pages) $18.56
Encrypted USB Drive $50.07
Expedition Charge $10.00
Certification Charge $2.00
Postage Due (current rate) $3.50 (Can vary based on destination and/or weight) 
Fed Ex Overnight Express Rate varies upon destination

Other Forms

The following forms allow you to make changes to how your personal health information is used. To make requests with the following forms:

  1. Download and complete the form
  2. Print and sign the completed form
  3. Provide a copy of your ID with a signature for verification
  4. If you have any questions, call the phone number provided in the form
  5. Fax completed form to the fax number provided in the form

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

Online Resources

myProvidence

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

MyChart

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.