Advance Health Care Directive (Living Will)
At your request, Queen's can provide you with an Advance Health Care Directive or Living Will. You may download the "Advance Health Care Directive" form (available in PDF below) to print out and complete. The form must be signed by you in the presence of two witnesses, or notarized. If you have any questions about Advanced Directives or Living Wills, feel free to call Queen's Patient Relations department at 808.691.4602.

There is no charge for physicians and other health care facilities (for direct patient care) if sent directly to a physician or health care facility and requested by them. If a patient requests that information to be sent to the physician or health care facility at the direction of the health provider, it will first be verified before any records are sent.

All other requests are billed directly to the receiver of the medical records (e.g. attorneys, vocational rehabilitation, etc.). For personal and out-of-state requests, fees must be paid in advance.

Download the Advance Health Care Directive form

Reproduction of Medical Records
All requests for Medical Information must be made in writing to Queen's Medical Records Department, Release of Medical Information Section. (The Medical Records department does not have radiology films or billing records.)

You may download the "Authorization to Release Medical Information" form (available in PDF below) to print a hard copy and then complete. All requests for Medical Information must be accompanied by this form and signed by the patient, legal guardian or next of kin.

Mail completed and signed authorization form to:
       The Queen's Medical Center
       Medical Records Department
       1301 Punchbowl Street
       Honolulu, HI 96813
The completed form may also be Faxed to 808.691.7806. If you have any questions, please call The Queen's Medical Records department, Release of Medical Information Section, during regular business hours, Monday through Friday, 8:00 am to 4:30 pm.

Download the Authorization to Release Medical Information form

Duplication Fees
Patient Request (Payment required for personal use)
Charges for copies:

• $.25 per page for hard copies
• $.50 Per page for records that are on microfilm

There is no charge for physicians and other health care facilities (for direct patient care) if sent directly to a physician or health care facility and requested by them. If a patient requests that information to be sent to the physician or health care facility at the direction of the health provider, it will first be verified before any records are sent.
All other requests are billed directly to the receiver of the medical records (e.g. attorneys, vocational rehabilitation, etc.). For personal and out-of-state requests, fees must be paid in advance.

Download Queen's Patient Rights & Responsibilities

Download Queen's Customer Comment Form