Request Medical Records (Health Information Management)

A.  Download, Print, Complete and Fax (or Mail) Authorization Form

• English Version
• Spanish Version

Once you have completely filled out the forms, fax them to:  (323) 361-1106 

B.  Or (if you cannot download and fax the above documents, you may Write a Letter and include

• Patient's Name 
• Patient's Date of Birth
• List of requested information  (e.g. surgery report, x-ray report, discharge summary, clinic visit notes, history and physical report, etc) 
• Purpose for the request  (personal use, for your physician, attorney, immigration, court, etc.) 
• Address where the information is to be MAILED
• Contact phone number of legal guardian (and recipient, if different)
• Legal guardian's signature
• Legal guardian's relationship to patient (i.e. parent, grandparent, self)

Please note: If patient is over 18 at the time of the request, the patient must authorize release of their medical records (unless they are physically unable to do so).

C.  Submit your request

C. Cost

The cost for requested records is dependent upon the purpose of the request:

• Personal:  $0.25 cents per page, plus tax and postage
• Medical:  No cost
• Other:  Contact the "Release of Information" Department directly at (323) 361-2387 between 8:30 a.m. - 4:30 p.m. for further details
  

D.  Phone Inquiries

For questions or more information, you may call (323) 361-2387.  You will be prompted to select English or Spanish as your language of choice, and then be provided with the following options for more information:

• Press 1 to obtain information about how to obtain copies of a patient's medical record
• Press 2 to discuss a bill
• Press 3 to be transferred to the X-ray or Radiology Department
• Press 4 for other inquiries or to check status of a medical records request
• If none of the selections above accommodate your needs, you may remain on the phone for a representative to assist you