Patient Health Information Request
To obtain medical records copies, a signed authorization is required from
the patient or authorized representative*.
*Authorized representative includes parent of a minor patient (under 18
years of age), legal guardian, or is named in the patient’s Advance
Health Care Directive as agent to make health care decisions. Proof of
representation will be required before records will be released.
IMPORTANT: While you are requesting a copy of your medical records here,
a signed copy of the request form along with a photo ID must be presented
at the time you pick up your records. Simply submitting a request for
records through this website is not a complete request, only an alert
to the hospital that you would like a copy. You must call for a pick up
appointment and provide the necessary ID and any charges that may be applied
at the time you arrive.
Picking up Copies of Medical Records
When you pick up copies of your medical records, you must provide photo
identification (state drivers license, state ID, passport, or military
ID’s are forms of valid photo identifications) in order to verify
we are releasing the information to the correct individual.
If you are unable to pick up your own records and someone else is picking
them up for you, you must provide a note giving PVHMC permission to release
your information to that person. The individual must then provide their
own photo identification at time of pick-up.
Please complete and print the form below and bring it with you when you're
picking-up your records.
If you have any questions, please call