About Us
Find a
Location:
Find a Location
or
Find a
Provider:
Find a Physician
and/or

Patient Forms

At Centura Health, we understand that managing your healthcare can be a complicated and confusing process. To help assist you with the coordination and management of your healthcare we have provided the Patient Request to Access Medical Records and Patient Authorization to Disclose PHI forms below for you to download at your convenience.

These forms can be used by patients, or their legal representatives, to access and obtain copies of their medical records and authorize the disclosure of their protected health information to third parties.

Forms 

 Patient Request to Access Medical Records [PDF-298KB]

 Patient Request to Access Medical Records (Spanish) [PDF-636KB]

 Patient Authorization to Disclose PHI [PDF-537KB]

 Patient Authorization to Disclose PHI (Spanish) [PDF-617KB]


You must have the free Adobe Reader to view these forms. Download it for free.


Centura Health is required by state and federal law to obtain a complete and properly executed authorization before we can provide access to or copies of health records. All completed forms should be printed and returned to the health information management or medical records department at the Centura Health facility, practice, or entity where you received care. A valid ID will be required for the health information management or medical records department to verify your identity.

For more information

If you have additional questions about obtaining your medical records, please contact the health information management or medical records department at the Centura Health location you normally visit.

Text Only Options

Change the current font size: larger | default | smaller

Current color mode is Black on White, other available modes: Yellow on Black | Black on Cream

Current color mode is Yellow on Black, other available modes: Black on White | Black on Cream

Current color mode is Black on Cream, other available modes: Black on White | Yellow on Black

Open the original version of this page.