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 and mail or fax it. (See information below).

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

Olympia Medical Center is a physician owned 204-bed acute care medical/surgical facility, providing award-winning inpatient and outpatient diagnostic, medical and surgical services to our communities.