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.

In the section below, provide your personal information.

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

Legal last name.

Legal first name.

Optional. Legal middle initial.

Date of birth of of individual or client.

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

Prior legal name, maiden name, or alias.

Full address and contact information of individual or client

List street address here.

List city here.

Pick state from the list below.

List ZIP Code here.

List 10 digit phone number here.

List complete email address here.

Please enter the selected identification number here.

In the section below, provide your personal information.

Legal last name.

Legal first name.

Optional. Legal middle initial.

List street address here.

List city here.

Pick state from the list below.

List ZIP Code here.

List 10 digit phone number here.

List complete email address here.



Program holding records (check all that apply)

Program holding records. Check all that apply.

If you checked "Other(s) or unknown" above, describe here. Name the program(s) here or what you mean by "unknown." For example, "Oregon Health Plan records," or "I was in a DHS program two years ago, but I don't remember the name."

If you checked "Other(s) or unknown" above, describe here. Name the program(s) here or what you mean by "unknown." For example, "Oregon Health Plan records," or "I was in a DHS program two years ago, but I don't remember the name."

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"

List the date ranges for your records request:

Start of date range.

End of date range.

Select the preferred format to receive the record.

Individual Acknowledgement

    Click here to attach the filled and signed authorization form.

    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.

    Click here to open the signature dialog.

    Click here to open the signature dialog.

    Signer full name

    Signer's legal last name.

    Signer's legal first name.

    Optional. Signers legal middle initial.

    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 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 wher you wish correspondence related to this request to be delivered.

    v. 20190801-1140

    Department of Human Services