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 – for you to print and ﬁll out.
You can either mail the completed authorization to:
Olympia Medical Center
5900 W. Olympic Blvd.
Los Angeles, CA 90036
Or you may fax the form to (323) 932-5376.
There may be a fee for the copying and mailing of your medical record. If you have any questions, please contact us at (323) 932-5275.
Health Information Management