We are committed to providing a website that is accessible to the widest possible audience. To do so, we are actively working with consultants to update the website by increasing its accessibility and usability by persons who use assistive technologies
such as automated tools, keyboard-only navigation, and screen readers.
We are working to have the website conform to the relevant standards of the Section 508 Web Accessibility Standards developed by the United States Access Board, as
well as the World Wide Web Consortium's (W3C) Web Content Accessibility Guidelines 2.1. These standards and guidelines explain how to make web content more accessible for people with disabilities. We believe that conformance with these standards and
guidelines will help make the website more user friendly for all people.
Our efforts are ongoing. While we strive to have the website adhere to these guidelines and standards, it is not always possible to do so in all areas of the website.
If, at any time, you have specific questions or concerns about the accessibility of any particular webpage, please contact WebsiteAccess@tenethealth.com so that we may be of assistance.
When filling out the form, it is important to ensure that the form is completed entirely in order to process your request.
Fill out the patient information in the top section, and be sure to include a contact phone number.
Any questions regarding highly confidential information should be directed to the Release of Information staff at (714) 524-4848. This section only needs to be completed if any of the items apply and require a separate signature.
Fill in the name and address of the recipient with the name of persons or class of persons to whom Placentia-Linda Hospital can disclose your health information. Example: Dr. John Smith. Please include a phone number for the recipient.
Fill in the spaces for the term during which your authorization will remain in effect. This should be a date in the future, up to 12 months from the date of the request. Example: If you sign the form 01/12/2017, then date this section 01/12/2018.
Married people are not allowed to sign for their spouses unless they have a legal power of attorney and their spouse is incapacitated.
Adult children are not allowed to sign for a parent unless they have a legal power of attorney and the parent is incapacitated.
In general, parents must sign for all minors under the age of 18 years.
Printed and completed forms can be returned to the Placentia-Linda Hospital Medical Records Department in the following manner:
Mail the form to: Medical Records Department 1301 Rose Drive, Placentia, CA, 92870