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Release of Information

Authorization for Use or Disclosure of Protected Health Information Access to Protected Health Information Form

In order to process your request for medical records, please complete all the fields on the ‘Authorization for Release of Information’ form. Please pay careful attention to complete all areas of the form. If not completed, we may need to return your request for more information.

Please call 701-845-6542 with questions about release of medical records or if you need assistance completing the authorization form.

Once you have completed and signed the form(s), utilize one of these options:

Fax it to:

Mail it to:
CHI Mercy Health Valley City
HIM Department
570 Chautauqua Blvd
Valley City, ND 58072

Return it to the facility Registration Office and the authorization will be hand delivered to the HIM Department and your request processed.

Thank you,

CHI Mercy Health VC HIM Department

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