Request form

Request for Access to Personal Medical Records

To ensure the highest level of confidentiality and in compliance with State and Federal Laws, the Pasadena Clinical Group, APC has adopted specific guidelines for its patients/clients to obtain copy of their medical records. If you are requesting a copy of your records for your current treatment (ex. psychotherapy) a summary is usually sufficient and is free of charge. There is a fee to process requests for medical records as specified below. 

Instructions: 

  • Complete the form below entirely. If any area is left unanswered or blank, or any part of the information is incorrect, the form becomes legally invalid per federal law. Each time you request a document from us a new authorization must be filled out; this is done to ensure HIPPA compliance so that your request can be processed without delay. 
  • There is a cost of $0.25 per page (California Health & Safety Code §123110); a down payment of $15 or $20 (depending on the documents requested) will be charged at the time your request is processed. Any balance will be charged to your credit card automatically; any credit will be refunded directly to the credit card used, no exceptions. 
  • We accept only credit card: once you have submitted all the information your credit card will be processed within 2 to 3 business days (excluding week-end and holidays), then your request to access your medical records will be processed. 
  • Once you have completed this online form you must download and fill out a paper form: this is done to protect you, the consumer, against those who would fraudulently use your personal information, including personal health information contained in your medical records. Without this form we will not be able to verify your request and the request cannot be processed. You can also fill out this form at the office, in person. 
  • Once your records are ready for pick up we contact you and schedule an appointment to pick up your documents. Courtesy services, such as faxing, emailing or postal mailing are available for a flat fee. You can verify the cost associated to any of these services at this link 

Requesting party