Records Request - Request someone else's records or my own

Provisions

We may not be able to provide access to, or copies of, some records or information including but not limited to:
- Psychotherapy notes
- Records or information that is no longer available
- Records you are not entitled to receive under law, Oregon Administrative Rule, or Agency policy
- Records not contained in the designated record set
If we deny all or a portion of your request, you have a right to request a review.
You may be charged a fee for copying your records.

I am requesting record(s) for:

Myself

Someone else

You will need a release of information. Do you have:

I will provide a 3rd party release.

I will complete a Release of Information form (MSC 3010).

In the section below, provide your personal information.

In the section below, provide the personal information of the person this request is for.

Last name:

Legal last name.

First name:

Legal first name.

MI:

Optional. Legal middle initial.

Date of birth:

Date of birth of of individual or client.

Any prior legal name(s), maiden name(s), or alias(es).

Other Name

Prior legal name, maiden name, or alias.

Full address and contact information of individual or client

Street address

List street address here.

City

List city here.

State

Pick state from the list below.

ZIP Code

List ZIP Code here.

Phone number:

List 10 digit phone number here.

Email address:

List complete email address here.

Case identification number, if known:

Please enter case identification number here, if known.

In the section below, provide your personal information.

Last name:

Legal last name.

First name:

Legal first name.

MI:

Optional. Legal middle initial.

Street address

List street address here.

City

List city here.

State

Pick state from the list below.

ZIP Code

List ZIP Code here.

Phone number:

List 10 digit phone number here.

Email address:

List complete email address here.

List the type of record or information requested:

List the type of record or information requested. For example:

"All APS and licensing inspection reports on (name of facility) for 2018"

"All Child Welfare records regarding (individual/client/child), specifically all foster parent records, screening reports and assessments" (For a high profile media case involving the death of a current or former foster child.)

"All DHS grants and contracts from (date range) with congregate care facilities, including BRS facilities"

"Children in Need of Placement data"

Reason for request:

List the date ranges for your records request:

Date From

Start of date range.

Date To

End of date range.

Select the preferred format to receive the record.

Mail

Pick up in person

USB flash drive

Individual Acknowledgement

Click here to attach the filled and signed authorization form.

If you are requesting someone else’s records and you have a release or authorization form signed by them, please upload it here.

Privacy laws restrict certain information from being released without permission. Authorization forms allow for the release of protected information to a person or organization that you choose.

Click here to download authorization form. Right click and save on PC then fill out and attach to this request and open the form in Acrobat Reader to complete. If using your Mac Magic Trackpad or built-in Multi-Touch trackpad, click or tap with two fingers. On Mac computers, right click is known as secondary click or Control click. If your mouse, trackpad, or other input device doesn’t include a right-click button or other way to perform a right click, just hold down the Control key on your keyboard while you click.

If you are requesting the release of an individual’s confidential records, such as medical or employment records, DHS must receive a signed authorization from the individual.

Full legal signature of individual or a person legally authorized to act on behalf of the individual:

Click here to open the signature dialog.

Signer full name

Last name:

Signer's legal last name.

First name:

Signer's legal first name.

MI:

Optional. Signers legal middle initial.

Personal representative authentication

Relationship to individual:

Additional Help and Resources

File a complaint.

Show “Right to access your records” information.

For questions please contact: Email: DHS.RecordsRequest@dhsoha.state.or.us Fax: 503-581-6198

This document can be provided upon request in alternative formats for individuals with disabilities or in a language other than English for people with limited English skills. To request this form in another format or language, contact your local office. For a list of local offices please see https://www.oregon.gov/DHS/Offices/Pages/index.aspx.

To request this form in another format or language, contact the Publications and Creative Services at 503-378-3486, 711 for TTY, or email dhs-oha.publicationrequest@state.or.us

Provide the email address where you wish receipt of request to be delivered. If no email, please put na@na.com

Enter the email address where you wish correspondence related to this request to be delivered.

Enter the email address wher you wish correspondence related to this request to be delivered.

Re-enter the email address where you wish correspondence related to this request to be delivered.

Re-enter the email address wher you wish correspondence related to this request to be delivered.

v. 20190801-1140

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