NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
170-Privacy Notice.HIPAA FORM.07.09.07CHH.doc
RELEASE OF INFORMATION FORM
TO HAVE MEDICAL RECORDS FROM CEDAR HILLS HOSPITAL SENT TO YOU OR SOMEONE ELSE, PLEASE COMPLETE THE RELEASE OF INFORMATION FORM IN THE LINK BELOW. ONCE COMPLETED YOU MAY MAIL, FAX, OR HAND DELIVER YOUR FORM.
NEW ROI Form.docx
MAIL OR HAND DELIVER TO
CEDAR HILLS HOSPITAL
10300 SW EASTRIDGE STREET
PORTLAND, OR 97225-5004
MEDICAL RECORDS FAX #:
Medical Record Copying Fees
Cedar Hills Hospital charges, as allowable by the state of Oregon (see below), for copies of medical records to patients or their representatives.
Cedar Hills Hospital does not charge for copies of records sent to health care providers for continuity of care.
Cedar Hills Hospital Copying Fees:
- $30 for the first 0-10 pages
- $.50 per page for pages 11-50
- $.25 per pages 51 and up
ORS 192.521 Health care provider and state health plan charges
A health care provider or state health plan that receives an authorization to disclose protected health information may charge:
YOU WILL RECEIVE A RESPONSE APPROXIMATELY FIVE TO SEVEN BUSINESS DAYS AFTER WE RECEIVE THE COMPLETED FORM. IF YOUR REQUEST IS DENIED, A HEALTH INFORMATION MANAGEMENT REPRESENTATIVE WILL CONTACT YOU.
- No more than $30 for copying 10 or fewer pages of written material and no more than $.50 per page for pages 11 through 50 and no more than $.25 for each additional page
- Bonus charge of $5 if request for records is processed and records are mailed by first class mail to the requester within seven business days after the date of the request.
- Postage costs to mail copies of protected health information or an explanation or summary of protected health information, if requested by an individual or a personal representative of the individual
- Actual costs of preparing an explanation or summary of protected health information, if requested by an individual or a personal representative of the individual
Cedar Hills Hospital Health Information Management