Patient Records Request

Health Information Management

Previously known as Medical Records, the Health Information Management (HIM) Department at Arroyo Vista Family Health Center is responsible for gathering, storing and managing the medical records of current and former patients. HIM team members help to ensure that each medical record is accurate, timely, complete and secure.

Above all else, the department is responsible for protecting the privacy of all personal health information. That includes carefully controlling the release of patient information so that only individuals and entities that have a legal right to view information may gain access to it.

How To Get A Copy Of Your Medical Record Three (3) Easy Steps

Step 01

You must fill out and submit a ROI authorization form (“Release of Information Authorization form”). There are a few ways to get access to this form:

English ROI form
Spanish ROI form
Online - You can view the blank form with Adobe’s Acrobat Reader, print it out, and fill it in by hand.
In person ( Lincoln Heights Office ) . Our office is open Monday through Friday between 8:00 a.m. and 5:00 p.m.
By phone—Call the Health Information Management (HIM) office at 323-987-2095, Monday through Friday, between 8:00 a.m. and 5:00 p.m. Our staff can mail, email or fax an ROI form to you.

ROI authorizations MUST contain the following information. If any of these items are missing from the form or if the form is not signed and dated, your request will be returned.

Patient information:

Patient’s full name (list any other names the patient may have had)
Date of birth
Medical record number (if available)
To whom the records will be released (name and full address)
Purpose for which the information may be disclosed (such as personal use, continuity of care, legal matter, insurance)
The health information being requested (clinic visit notes, prenatal records, etc.)
Your initials to acknowledge release of sensitive information. Information related to Drug and Alcohol abuse treatment, Mental health or Psychiatry treatment records, HIV test results, or Genetic Test results will NOT be released without an initial.
A written signature is preferred for verification purposes , Docusign is also acceptable. Electronically typed names are not accepted as a signature.
Records can be released to anyone whom the patient authorizes (in writing) to receive them. If an expiration date is not noted, the authorization is valid for one year.
Disclaimer: We do not accept attorney requests for medical records via email. All requests must be submitted by certified mail and must include a $15 processing fee paid by check.

Step 02

The ROI authorization form must be filled out either by the patient or the patient’s legal representative. If the medical record you’re requesting is your own, you must provide current government-issued ID.

If you are requesting a medical record for another person, you must submit that person’s current government-issued ID and your own identification.

Authorizations signed by a representative must be verified by including a copy of one of the following documents:

Legal guardianship papers
Advance directive or health care power of attorney, for patients unable to make health care decisions
Advanced Healthcare Directive Form

Designation of a personal representative, which allows the representative to act on the patient's behalf with regard to personal health information (only pertains to independent patients who want to identify a personal representative).
HIPAA Authorization Form
English
Spanish
Requests for medical records of deceased patients require a copy of the death certificate or evidence of next of kin or executorship of the estate.

Step 03

Submit your completed ROI Authorization form. (See how to submit below.) In order for your request to be valid and processed, please fill out all fields on the form.

We are unable to process incomplete ROI authorization forms.

Click to view sample guide to complete an ROI forms.

How to Submit:

In person — ( Lincoln Heights Office)
By mail — (Lincoln Heights Office)
By email — (healthinformation@arroyovista.org)
By fax for only continuation of care requests — 323-987-1450

Cost and Timing

The charge for a medical record depends on the source of the request:

Insurance company or attorney requests—A $15 processing fee is required for all insurance and attorney record requests. Payment must be made by check only.
Your physician or patients for continuation of care —no charge
Your physician—no charge
Please allow up to 3-5 business days to process your ROI request.

English

Spanish