Releasing Your Medical Records:
To obtain a copy of your medical records, please see the instructions below and click on the link (Microsoft Word document) to complete the authorization form.
If you have any questions, please contact our Health Information Services Department at (714) 524-4846.
AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION
1. Fill out the name of the patient as he/she was registered at the time of service in the hospital.
Example: “Jones, Robert E.” instead of. “Jones, Bob”
2. Fill in the patient’s phone number including area code.
Example: “ 714- 524-4846”
3. Fill in the patient’s date of birth of the patient using month/day/year.
4. Fill out the complete home address with number, street, city, state and ZIP code.
5. Specify the date of service and type of records to be disclosed.
Example: “Xrays taken on 07/01/2001.”
6. Any questions regarding HIGHLY CONFIDENTIAL INFORMATION should be directed to the Release of Information Officer at phone number 714-524-4848.
7. **It is very important that you fill in the space for; “RECIPIENT: Name of person or class of persons to whom Placentia-Linda Hospital may disclose my health information:”
Example: “Dr. John Smith”
8. **It is very important that you fill in the space for: “Address of the recipient or where my health information should be delivered:”
Example: “Sunnyside Medical Clinic 1234 West 1st Street, Sometown, CA 92123”
9. **It is very important that you fill in the space for: TERM: This Authorization will remain in effect: From the date of this Authorization until the _______ day of ______, 200__.” This should be a date IN THE FUTURE up to six months from the date of the request.
Example: If you sign the form 01/12/2003, then date this section 06/12/2003.
10. Married persons are not allowed to sign for their spouses unless they have a Legal Power of Attorney and their spouse is incapacitated.
11. Adult children are not allowed to sign for their parent unless they have a Legal Power of Attorney and their parent is incapacitated.
12. In general, parents must sign for all minors under the age of eighteen (18) years.
Call Placentia-Linda Hospital with any questions regarding age requirements.
13. Completed forms may be returned to the Placentia-Linda Hospital Medical Records department by any of three options:
1) Mail form to: Medical Records Department 1301 Rose Drive, Placentia 92870
2) Bring the form in to the Medical Records department in person
3) Fax to the Medical Records department at: 714-524-4867 (be sure to fax both sides).
Authorization Form to request a copy of your medical record. Please print, complete and submit.
X-Rays and Films:
To obtain a copy of your X-Rays or films, we ask that you call our Radiology Department at 714-524-4820 so we may retrieve your file prior to you coming in.
We also ask that you provide us with a 24-hour notice. When you pick up your films, you will need to complete and provide us with the Authorization and Release form. Attached is a copy for your convenience. You may bring the form in person or fax it to our Radiology Department at 714-524-4216.
Authorization Release Form for Films: ReleaseFormFilms.pdf