Request for Access to Records


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Request for Access to Records

Date of Request:     Phone Number:     Name:     Date of Birth:

     I am requesting copies of the following specific information:  

     I am requesting these copies for the following reason:  

I understand that my request may be denied. If my request is denied, CFD will provide me with a written explanation of the denial within 5 business days of this request. I may request that this denial be reviewed by a person other than the person who denied my request.

My signature affirms that I have read and understand this form and have had the opportunity to ask questions.

This document is being signed by:

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.


Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.


*** NOTE: There may be a charge for copies and staff time; however, access to records will not be denied because of inability to pay. ***

Leave this empty:

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Signature Certificate
Document name: Request for Access to Records
lock iconUnique Document ID: 773e6297e099f96e837106ae8bb2e6d87a255716
Timestamp Audit
May 29, 2020 11:49 am PDTRequest for Access to Records Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
June 2, 2020 4:27 pm PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
March 18, 2021 2:47 pm PDT Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:47:19 - 65.157.96.202
March 18, 2021 2:47 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
May 3, 2021 10:29 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202