Medical Records Request — English - My Chula Vista Doctors

Patient Information

Patient Legal Name

Date of Birth

Phone Number

Email

Request Type - Choose One

I request that records be

Sent TO My Chula Vista Doctors Medical Clinic Released FROM My Chula Vista Doctors Medical Clinic Released to me

Records Requested

Specially protected information: If these records include HIV/AIDS status, mental health/psychiatric records, substance use disorder treatment records, genetic information, reproductive/sexual health information, or other specially protected information, I authorize disclosure only as indicated below.

Receiving / Sending Facility or Person

Facility / Person

Phone

Fax

Email

Address

Delivery Method

I understand that email may not be a secure method for HIPAA-protected information. If I request email delivery, I accept the risks of unencrypted email unless secure email is used.

Authorization and Expiration

I understand that this authorization is voluntary and that refusing to sign it will not affect my ability to receive treatment, payment, enrollment, or eligibility for benefits unless allowed by law. I may revoke this authorization in writing, except to the extent action has already been taken in reliance on it. Unless a shorter date is written below, this authorization expires one (1) year from the date signed.

Please attach a copy of a valid photo ID, such as driver license, passport, military ID, or state ID.

Expiration date if less than one year

Purpose of request

Signature of Patient / Representative (type full name)

Printed Name and Relationship

Date