Request for Release of Medical Records

If you are a patient requesting a release of your medical records, please complete and download the following form.  THE FORM MUST BE ACCOMPANIED BY A SIGNED AND DATED PHOTO IDENTIFICATION SUCH AS A DRIVER’S LICENSE OR PASSPORT. You may then fax the form and the signed and dated photo identification to us at (310) 273-0314.

(Click on the hyperlink above to open, fill in the form, download, print and fax to us. THE FORM MUST BE ACCOMPANIED BY A SIGNED AND DATED PHOTO IDENTIFICATION SUCH AS A DRIVER’S LICENSE OR PASSPORT. )

Once you have submitted the forms, please call our office at (310) 273-2310 to confirm receipt of your information.