Release of Medical Record Information

Vancouver Clinic values your privacy. Requests for release of information must be made in writing and signed by the patient or their legally authorized representative. Our forms are available here or at any of our clinic locations.

You may mail or fax the completed form back to us, or drop it off at any of our clinic locations.

Please be advised that there may be a fee associated with your request.

You may revoke a signed authorization at any time by filling out a revocation form here, or at any of our clinic locations.

Medical Records Delivery Options

• A patient can opt to receive copies of their own records on paper, on CD or via electronic delivery. Paper records or records on CD can be mailed or picked up at our Release of Information department.
• Records can be mailed to a designated recipient.

Request of Records from another facility on patient’s behalf
Due to the wide variance of requirements involved, generally we do not. If you want records transferred to Vancouver Clinic from another facility, please contact that facility directly to request a transfer. If you are unable to obtain your records, contact the Health Information Supervisor for assistance at (360) 397-4433.

If you have questions
If you have questions about your medical record, you may call (360) 397-3638 during our office hours and a Release of Information Specialist will assist you.

Our Medical Records Release of Information Office location
13898 NE 28th Street, Suite B 109
Vancouver, WA 98682

(Please do NOT send mail to this address)
Fax: (360) 604-1714

**Please note that patients must visit an Imaging Department suite in any clinic (except Washougal) to collect imaging records. These are not available at our Medical Records office location.

Mailing Address
Vancouver Clinic
Medical Records
700 NE 87th Avenue
Vancouver, WA 98664-4896

Our office hours are 8:00 to 5:00 Monday through Friday

Authorization Form Instructions

Consent for Treatment of Minor Children

Accompanied visits:

1. The form must be filled out and submitted prior to the appointment.
2. List the full name of other adults (18 or older) who can accompany your minor child to appointments when you are unable to attend.

Unaccompanied visits:

1. EXCLUSIONS: minor medical procedures such as wart, mole, or toenail removal, etc.
2. The form(s) must be filled out and submitted prior to the appointment.
3. You must have an existing, valid phone number on file in your minor child’s chart where we can reach you for verification purposes.
4. If your child will be receiving immunizations during this visit:
   1. In addition to the Consent for Treatment of Minor Children Form, you will also need to fill out the Child and Teen Immunization Screening Questionnaire found under the “Forms” tab.
   2. NOTE: one screening form is required for each immunization visit, every time immunizations are given.
   3. Both forms are required in order to administer immunizations to an unaccompanied minor.

Authorization to Discuss/Disclose Protected Health Information

1. Click on the “Forms” tab and print the form.
2. The required fields on the form are marked with an asterisk (*).
3. You can list up to three individuals per form.
4. Print your full name and date of birth.
5. Print the individual(s) name, relationship to you, and their phone number.
6. Specify whether the listed individual(s) are authorized to any/all information or only specific information.
7. Write in a specific expiration date or select “until revoked in writing.”

Authorization for Use or Disclosure of Protected Health Information

1. Click on the “Forms” tab and print the form.
2. The required fields on the form are marked with an asterisk (*).
3. Print your full name and date of birth.
4. Provide complete name and address of the facility where you want the records sent. Providing phone number and fax number is optional but helpful if you have it.
5. Specify the information that you wish to be disclosed.
6. Specify any exclusions (sensitive information- see form).
7. List purpose of disclosure (e.g. transfer of care, etc.).
8. Understand that if you wish the authorization to be valid for longer than a one-time release, you must specify that on the form.
9. Understand that there may be a fee associated with your request.
10. Sign and date the form.
11. If signing the form on behalf of the patient, you must list your relationship to the patient (e.g. POA, parent, legal guardian, etc.).

Patient Request for Records

1. Click on the “Forms” tab and print the form.
2. The required fields on the form are marked with an asterisk (*).
3. Print your full name and date of birth, address, and phone number.
4. Specify the information needed.
5. Specify delivery option: paper records, records on CD, direct the records to a third party of your choosing, or electronic delivery.
   1. You can opt for mailing or pick up of paper records or records on CD.
   2. If you want electronic delivery of the records you will need to provide an e-mail address.
   3. Radiology images can only be mailed. If your request contains both paper records and images- the request will be processed and delivered separately.
6. Understand that there may be a fee associated with your request.
7. Sign and date the form.
8. If signing the form on behalf of the patient, you must list your relationship to the patient (POA, parent, legal guardian, etc.).

Electronic Delivery of Patient Records
You will be notified via e-mail when the records are ready and how to access them. You will have 30 days from when you are notified to view, download, or print the records from our secure website.

Does Vancouver Clinic charge for records?
Yes, in some cases. Please contact the Release of Information Department at (360) 397-3638 for details and see the Fee Schedule in the tab to the right.

If I want my records mailed, how long does it take?
It typically takes 7-10 days to receive records from the date requested.

If I want to pick up records, where do I go?
The Medical Records Release of Information Department
13898 NE 28^th Street, Suite B-109, Vancouver, WA 98682
Phone: (360) 397-3638 | Fax: (360) 604-1714
Walk-in Hours: 8 a.m. – 5 p.m., Monday – Friday

Do I need to bring a picture ID?
Yes

If I want my records sent to another facility, what form do I use?
Authorization to Use or Disclose Protected Health Information (Release to a Third Party) (see Forms tab)

If I want a copy of my own records, what form do I use?
Patient Request for Records (see Forms tab)

If I want to authorize Vancouver Clinic to discuss my medical information with another individual of my choosing, such as my spouse, caregiver or children, what form do I use?
Authorization to Discuss Protected Health Information (see Forms tab)

If I want to come in and look at my medical records, how do I set up an appointment?
Call the Health Information Supervisor at (360) 397-4433.

Will Vancouver Clinic request records from another facility on my behalf?
Due to the wide variance of requirements involved, generally, we do not. If you want records transferred from another facility, please contact that facility directly. If you are unable to obtain your records, contact the Health Information Supervisor for assistance at (360) 397-4433.

If I want to know if my records have arrived, who do I call?
The Medical Records Department at (360) 397-3611.

Can I transfer my records to Vancouver Clinic before I have an appointment scheduled?
Yes.If the patient is not registered in our system we will hold the records for 30 days.

Can I walk into the Medical Records Release of Information Department?
Yes, we accept walk-ins from 8 a.m. to 5 p.m. Monday through Friday. Please bring a picture ID.

If I requested both paper records and radiology images, will they come together?
No, imaging CD’s are mailed separately from the Imaging Department.

Can I request records of my minor child?
Yes.

Can I request the records on behalf of someone I am authorized to represent (i.e. Power of Attorney)?
Yes, a copy of the POA – which must be a HealthCare/Medical POA, is required.

Can I request records of a deceased family member?
Yes, if you are a person with legal authority to act on behalf of the decedent or the estate, or have authority to make health care decisions (i.e. HealthCare POA). Examples: Executor, or Administrator of the estate, HealthCare/Medical POA, Next of kin.  A copy of the death certificate is required.

As a parent/legal guardian of a Diminished Capacity minor, is there a way to maintain proxy access to my child’s MyChart@TVC account past the age of 13?
Yes, if Diminished Capacity can be established and the need for proxy access verified. Diminished Proxy Access can only be established by contacting the Medical Affairs Department at (360) 397-3150.

If I have trouble logging into MyChart@TVC account or need my password reset, who do I call?
Call the Patient Service Center at (360) 882-2778.

If I have court/legal documents regarding custody (parenting plans), adoption, guardianship, POA, Advanced Directives, etc. does Vancouver Clinic need copies?
Yes, when it comes to release of information these documents are necessary to help us to verify who is and who is not authorized to receive medical records.

Can my ex-spouse still get copies of my children’s records?
Yes, unless their parental rights have been legally removed. Only a court can restrict a parent’s access to the child’s medical records. If parental rights have been revoked, court papers are required for verification.

Can I request a link to the electronic record request form be sent to my cell phone?
Yes, contact the Release of Information Department Staff at 360-397-3638 to request a link.

Information about fees charged relating to Medical Records – Advance Notice