Patient Medical Records

IMPORTANT MESSAGE

While you are requesting a copy of your medical records here, a signed copy of the request form along with a photo ID must be presented at the time you pick up your records. Simply submitting a request for records through this website is not a complete request, only an alert to the hospital that you would like a copy. You must call for a pick up appointment and provide the necessary ID and any charges that may be applied at the time you arrive.

This authorization is used for the Use and Disclosure of Protected Health Information for reasons other than treatment, payment or healthcare operations.
PATIENT IDENTIFYING INFORMATION
*Patient's Name:
*Date of Birth:
I authorize Pomona Valley Hospital Medical Center ("Hospital") to use or disclose (release) the above named patient's health information as described below.

The following individual or organization is authorized to receive / review the above named patient's health records. If records are being released for Personal Use, there will be a fee of $15.00 for the first 10 pages and $0.25 per page thereafter.
RELEASE RECORDS TO
*Name / Organization:
*Phone Number:
*Email:
*Address:
*City:
*State:
*Zip:
Purpose (s) of Disclosure:
(including and limitations on use or disclosure):
INFORMATION TO BE RELEASED:







*I understand that the information in my health record may include information relating to sexually transmitted disease(s) (STDs), AIDS or HIV. It also may include information about behavioral or mental health services and treatment for alcohol and drug abuse.
Please check this box to acknowledge
YOUR RIGHTS
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility of benefits.

I may revoke this authorization at any time. My revocation must be in writing, signed by me or on behalf and delivered to Pomona Valley Hospital Medical Center ATTN: Health Information Management, Release of Information, 1798 N. Garey Avenue Pomona, CA 91767.

My revocation will be effective upon receipt but will not be effective to the extent that the Hospital or others have acted in reliance upon this Authorization. For further information, please see Hospital's Notice of Privacy Practices.

It is possible that the information disclosed under this Authorization could be subject to redisclosure by the recipient and no longer protected by federal or state privacy laws.

I have a right to receive a copy of this Authorization. I acknowledge that this Authorization was filled out completely when I signed the Authorization.

I understand that there may be circumstances that would allow the Hospital to receive a fee in exchange for disclosing the information requested on this Authorization.
DIGITAL SIGNATURE
*Name of Patient / Legal Representative:
*Date:
*Relationship to Patient / Authority to Act for Patient:
Witness:
Identification Verified
*Authorization Expires (Date or Event/Condition):
 
   
Pomona Valley Hospital Medical Center - 1798 N. Garey Avenue - Pomona, CA 91767 - (909) 865-9500 - Contact Us
For AssociatesPVHMC SITE MAP — Copyright © 2013, Pomona Valley Hospital Medical Center. All Rights Reserved. — Notice of Privacy Practices