As a patient of NorthBay Health, you have the right to obtain a copy of your medical records, or request that your records be sent to another treatment facility.
The Health Information Management department at NorthBay Health requires a signed Authorization to Use and Disclose Protected Health Information form when releasing medical records to anyone, including the patient.
How to obtain and complete the authorization form
- Print and complete the Authorization to Use and Disclose Protected Health Information Form:
- Spanish (coming soon)
- All boxes on the form must be completed and the form must be dated and signed. Failure to complete the form and date and sign it will invalidate the authorization and your request will not be processed.
Authorization to Use and Disclose Protected Health Information Instructions To request copies of your Health Record and/or Billing Statements, please complete the authorization form in its entirety. This form only authorizes NorthBay Health to release records.
Complete Numbered Boxes as Follows: (Please Print Clearly)
- Healthcare facility name and address you received treatment from.
- Patient Information.
- Date of Birth
- Telephone Number
- Requestor Information
- Requestor's full name
- Telephone Number
- Fax Number (if available)
- Check whether this request is for your personal use or for continuing care.
- Check the media preference you would like to receive your records: paper or cd.
- Check your delivery method preference of mail or pick-up.
- Enter the dates of your treatment from NorthBay Health that you would like your records released from. NorthBay maintains 10 years of records only
- Check the types of information of your health record you would like released.
- If you are looking for the release of highly confidential material (Mental Health Notes, HIV/AIDS test results) You must check the boxes AND initial in the space provided.
- Please date and sign the authorization in the space provided
- If you are a guardian or conservator for the patient, please state your legal relationship to the patient and provide documentation for validation.
- You can email your completed release to:
ROI-MedicalRecords@Northbay.org or Mail to: NorthBay/VacaValley Hospital, Attn: Medical Records, 1000 Nut Tree Rd, Vacaville, CA 95687
*There is a fee of $27.10 for patient requests over 100 pages (paper or cd). You will receive a text message from VRC when your records are ready and you have the ability to pay online.
**If picking up records in person we can only accept cash or check. Location for pick up is: Vacavalley Hospital, 1000 Nut Tree Rd, Vacaville, CA. Check in with the Security desk.
If you have any questions regarding the completion of the authorization form, please call the Health Information Management Department at 707-624-7040.