Medical Records Form
Dear Patient/Family Member,
If you are interested in obtaining a copy of the pertinent information from your medical record for your personal use, or would like it sent to another healthcare provider, please complete the Authorization form.
Click here for the "Authorization to Use and Disclose Protected Health Information" form.
You can either mail the completed authorization to:
Ms. Angie Gonzalez
ROI Coordinator
HIM Dept.
Olympia Medical Center
5900 W. Olympic Blvd.
Los Angeles, CA 90036
Or you may fax to Ms. Gonzalez at 323-932-5376.
They may be a fee for the copying and mailing of your medical record. If you have any questions, please contact Ms. Gonzalez at 323-932-5004.
Sincerely,
Carol Haydon, RHIA
Director, Health Information Management
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