MEDICAL RECORDS

The clinic maintains medical records for the time period required by the State of California. How to request a copy of your medical record:

According to the State of California’s Confidentiality of Medical Information Act, the clinic must receive a complete and properly executed authorization before providing a copy of the patient’s records to anyone, including the patient. Authorizations signed by a patient representative must include a copy of the durable power of attorney, guardianship, etc. The clinic processes most requests in 5-7 business days, while large requests may require additional time. We may charge a fee for large requests.
You will need to complete the form and provide the information listed below:

• Indicate the dates of treatment/admissions for which you are requesting information
• Indicate the type of records needed, i.e. Lab results, x-rays
• Indicate if Radiology/Imaging CDs are needed and date and type of image: XRAY OR ULTRASOUND.

If you have any questions regarding the fees, please call 909-596-4879.

Service	Cost
Medical Records (1–50 pages)	$15
Medical Records (51+ pages)	$30
Billing Records	$15
Billing Records (51+ pages)	$30
Radiology Records |	$20

Authorization Form

Authorization for Release and/or Disclosure of Medical Information