PLEASE READ CAREFULLY BEFORE COMPLETING THE FORM
Thank you for trusting us with your healthcare needs; we look forward to meeting you and hope to exceed your expectations in every aspect of your behavioral treatment. Each employee at Pasadena Clinical Group is committed to enhancing the quality of your care and your overall experience.
The form below is called ROI, or Release Of Information. It refers to the process of disclosing your confidential health information to authorized parties. This can include your medical history, participation to therapy, your progresses, and other sensitive information. With some exceptions, this form allows you to disclose information to various parties, such as healthcare providers, family members, or legal representatives.
In the United States, the Health Insurance Portability and Accountability Act (HIPAA) outlines the rules and regulations for the release of patient health information. HIPAA ensures that patient information is protected and disclosed to authorized parties with the patient’s consent, or in certain circumstances where it is required by law. In order to release your information, we must obtain written consent from you.
Complete the form below in each part. Upon submission, our staff will review it in the order it is received, and processed in 1 to 5 business days. If any part is missing, it will become legally invalid.
To complete this form you will need a copy of your Driver’s License (or any other government-issued ID), and the exact full name, address, telephone number, and fax number of the person, or the agency, to whom you want your records to be disclosed.
All attachments must be in PDF, JPG, or HEIC format. We cannot accept emails or other means of verification.
Please set aside 10-15 minutes to complete the form.
If you prefer to mail your request, please download the form on your computer and mail it to:
Pasadena Clinical Group – Att. Medical Records
PO BOX 5512, Pasadena, CA, 91117
Should you have any questions, please do not hesitate to contact our office for help at 626-354-6440, Monday through Friday, from 8 am to 7 pm.