Medical Records Requests
To request that your medical records be sent to another entity, or to request that your previous records be sent to PANW, please follow the process below:
- Complete the authorization form to release medical information either FROM PANW or TO PANW.
*If the patient is 18 years and older, authorization forms must be completed by the patient (not a parent or guardian).
To release behavioral health information, please use this form.
2. Completed authorization forms may be returned via fax, mail, in person, or through our secure patient portal.
3. Once the authorization has been verified by our medical records department, your request will be fulfilled within 2 business days. Additional time may be needed for requests for images on CD or records retrieved from paper charts.
4. If fees apply, an invoice will be sent to you. Once payment has been received, records will be sent to you by your chosen method of delivery.
Records Request Fees
There may be fees for the release of records as permitted by state law (ORS 192.563) and HIPAA Privacy Rule 45 CFR 164.52(c)(4).
Payment for copying medical records is due and payable in advance of records being sent.
Pages 1-25: FREE*
Pages 26+: $25.00*
Electronic Copies: $15.00*
For 3rd Party:
Pages 1-10: $30.00
Pages 11-50: $0.50 per page*
Pages 51+: $0.25 per page*
Electronic Copies: $20.00*
*Postage fees apply, if mailed. No fee will be charged to release your records to another physician’s office, however a completed authorization form is required.
If records requested are over 10 years, there will be an additional fee to obtain them from storage.
Please make checks payable to “Pediatric Associates of the Northwest (PANW)” and write “Medical Records” in the “For/Memo” section of the check. For your convenience, we also accept Visa, MasterCard, and American Express.
Send your authorization form and payment to:
Pediatric Associates of the Northwest
2701 NW Vaughn St. Ste. 360
Portland, OR 97210
For questions regarding medical records, please contact us: