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Medical Records Requests

How to Request a Copy of Your Medical Records

Plumas District Hospital is happy to provide you with a copy of your health information.  To request a copy of your records, please download and fill out the form below:

Medical Records Request Authorization Form Medical Records Request Authorization Form (760 KB)

Please return it to the fax number or email provided below. (This contact information is also listed on the form). You will need to fill out the form completely, with your full name and contact information, birth date, and the specific treatment dates you are seeking. Please include a photocopy of your photo ID. We provide the first request at no cost to you.

Our staff will contact you regarding receipt of your request, expected turnaround time and payment due. For security purposes, at the time records are delivered to you, you will need to provide proper identification.

If you are requesting more than 20 pages, the following fee schedule based on California state law, will be used to determine the charges:

  • 0.10 cents per page for 8.5x14 inches or less
  • 0.20 cents per page for microfilm
  • Actual costs for the reproduction of oversize documents or the reproduction of documents requiring special process which are made in response to a subpoena
  • The reasonable cost of clerical costs incurred in locating and making records available 
  • Actual postage charges

For requests pursuant to Evidence Code Section 1158, please use the following form:

Authorization For Disclosure of Health Information Authorization For Disclosure of Health Information (641 KB)

and return it to the fax or email provided below.  The above charges apply:

Contact Information
Plumas District Hospital
Health Information Management
1065 Bucks Lake Road
Quincy, CA 95971

Phone: 530-283-7122 
Fax: 530-283-7197
Email to:  medicalrecords@pdh.org

Hours for medical records requests:
Monday - Friday: 8 a.m. to 5 p.m.
Closed on holidays