As a patient of NorthBay Healthcare, 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 Healthcare 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:
  • English
  • 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.

Complete the Numbered Boxes as follows: (Please Print Clearly)

1. NorthBay Healthcare hospital or clinic you are requesting records from.
2. Patient Information
   1. Name
   2. Date of Birth
   3. Address
   4. Telephone Number
3. Requestor Information
   1. Requestor's full name
   2. Address
   3. Telephone Number
   4. Fax Number (if available)
4. Check whether this request is for your personal use or for continuing care.
5. Check the media preference you would like to receive your record in paper or cd.
   1. You will be charged at a rate of $.25 per page for paper requests
   2. You will be charged at a rate of $.50 per page for microfilmed records
   3. You will be charged a flat fee of $6.50 for cd requests
   4. Payments for cd requests can only be made by check or money order, payable to NorthBay Healthcare. Hospital records are only available on CD for records from 6/1/2009 - present
6. Check your delivery method preference of mail or pick-up.
   1. For pick-up a phone call will be made to notify you of the completion of your request
   2. Requests received by fax will not result in records being delivered by fax
7. Enter the dates of your treatment from NorthBay Healthcare that you would like your records released from.
8. Check the types of Information of your health record you would like released.
   1. Often the Discharge Summary, History and Physical, and Operative Reports will be relevant information to suit your needs
9. To release the following highly confidential components of your record, please check the box and initial in the space provided:
   1. Mental Health Treatment Records
   2. HIV/AIDS Test Results and Treatment Records
   3. Substance Abuse Treatment Records
   4. Genetic Counseling Treatment Records
10. Please date and sign the authorization in the space provided.
    1. If you are a guardian or conservator for a patient, please state your legal relationship to the patient and provide documentation for validation

How to submit the form for processing

Once completed, the authorization form can be returned to the Health Information Management department, by mail, fax, or personally dropped off at the following locations:

NorthBay Medical Center
Attn: HIM Department
1200 B. Gale Wilson Blvd.
Fairfield, CA 94533
Fax: (707)646-5041

NorthBay VacaValley Hospital
Attn: HIM Department
1000 Nut Tree Road
Vacaville, CA 95687
Fax: (707)624-7041

NorthBay Center for Primary Care - Vacaville
421 Nut Tree Road
Vacaville, CA 95687
Fax: (707)624-7501

NorthBay Center for Primary Care - Fairfield
2458 Hilborn Road
Fairfield CA 94534
Fax: (707)646-5501

NorthBay Center for Primary Care - Green Valley
4520 Business Center Drive
Fairfield CA 94534
Fax: (707)646-3501

Please allow up to 15 days for processing.

If you have any questions regarding the completion of the authorization form, please call the Health Information Management Department at (707) 624-7040.