Release of Information Request

Please use this form to request access to your Protected Health Information (PHI) in the designated record set that we maintain.

You generally have the right to inspect and/or obtain a copy of your PHI in your designated record set from Northern Light Health.

Legal Notice

By law, we are not required to agree with your request for access to your PHI, and in certain situations, the law requires us to deny access.

If this is the situation, we will advise you of the reason for the denial. Under certain circumstances, you may be able to request a review of the denial.


If you request a copy of your records, Northern Light Health may charge a reasonable fee based on the cost of labor and materials to produce the copies. If we determine a charge is necessary, you will be notified prior to the records being sent.

Sensitive Information

If information contains sensitive information such as mental health/developmental disability, sexually transmitted diseases and/or alcohol/drug abuse, genetic testing or HIV/AIDS, please use our authorization form process.

Relationship to the patient:


Information to be Disclosed


Please send my records to:

Please send my records to

I verify that all the information I have provided is accurate.