How to Request a Copy of Images and Reports
Freestanding (except San Clemente)
Medical Center and MemorialCare Imaging Center - San Clemente
- Demographic Information. Please enter the following: name, address, phone, date of birth, last four digits of your Social Security Number.
- Section 1 asks, “What part of the medical record do I need?” The complete medical record contains every entry in our electronic system and may be considerably more information than you need. If you want more specific and/or limited information, choose the appropriate items under [OR the records marked below:], i.e. Radiology Films, Radiology Reports, Photographs, videotapes, or digital or other images, etc.
- Section 2 does not need to be completed unless you are asking for records that are outlined in this Section. If you are asking for these records, then choose the appropriate item and include your signature where indicated. If you are not requesting records outlined in this Section, you do not need to complete this area of the form.
- Section 3 asks, “How would you like your request to be handled?” Please be advised that in order to process your request, a valid Photo ID with signature, must be included with your authorization form.
- If you want someone to pick up your records on your behalf, please include the name of your Representative in the space provided. Please instruct your Representative that they must present a valid Photo I.D. matching the name listed in this section to obtain your records.
- If you want the information to be faxed, please provide the fax number.
- If any of the information is being faxed or sent to someone other than yourself; provide the name and address of the person who will receive your information.
- Section 4 asks, “How long is this authorization is valid?” If you do not list a specific date in the space provided, the authorization will be valid for a period of 90 days from the date of your signature. This Section requires that you provide your initials in the space provided.
- Section 5 outlines your Individual Rights as they pertain to this authorization form.
- Signature / Date / Time: In order to process your request, this section must be completed.
2. Cost For Processing: A fee of $0.25 per page will be assessed for paper copies. If you would like your information placed on a CD, a $5.00 fee applies. If you have questions related to the cost of obtaining your records, please contact the facility directly.
3. Submit the completed authorization form in person, by fax or mail to the appropriate Imaging & Radiology location where your images or X-rays were taken.