PLEASE READ CAREFULLY BEFORE COMPLETING THE FORM
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 copies 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. For all other types of records, 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).
- 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. The records are usually delivered to the email address we have on file, however, if you require extra services such as overnight shipping or other services, you will need to pay them apart. Please inform the office in advance of any extra services you need.
- To submit this form, you will need a copy of your Driver’s License (or any other government-issued ID).
- All attachments must be in PDF, JPG, or HEIC format. We cannot accept emails or other means of verification.
- Please set aside 6 to 8 minutes to complete the form.
- 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.
Note: this form can be completed using Google Chrome. Security restrictions may not allow this form to be completed from your cell phone or tablet.