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 909.865.9142.

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