Medical Records Forms

How to Request a Copy of Your Medical Records from a MemorialCare Medical Center:

Complete the "Authorization to Use and Disclose Protected Health Information" form:

• Authorization to Use and Disclose Protected Health Information - English
• Autorizacion Para El Uso y Divulgacion De Informacion Medica - Español

1. Demographic Information. Please enter the following: name, address, phone, date of birth, last four digits of your Social Security Number.
2. 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. History & Physical, Operative Report, Discharge Summary, etc.
3. 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.
4. 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.
   1. 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.
   2. If you want the information to be faxed, please provide the fax number.
   3. 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.
5. 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.
6. Section 5 outlines your Individual Rights as they pertain to this authorization form.
7. Signature / Date / Time: In order to process your request, this section must be completed.
8. 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.
9. Submit the completed authorization form in person, by fax or mail to the appropriate Medical Records Department where you received your care and treatment.

How to Opt-out of the Health Information Exchange:

Complete the "Patient Opt-Out Request" form:

• Patient Opt-Out Request Form 2019.pdf
• Patient Opt-Out Request Form 2019-Spanish.pdf

1. Complete the second page of the document, titled PATIENT OPT-OUT REQUEST FORM.
2. Include up-to-date contact details.
3. Sign and date the document. In order to process your request, the entire document must be completed, including the signature.
4. Submit the completed authorization form in person or mail to the appropriate Medical Records Department where you received your care and treatment. You can also mail the completed form to:

MemorialCare Compliance Officer
17360 Brookhurst Street
Fountain Valley, CA 92708

Our Medical Records Departments:

Long Beach Medical Center
Medical Records Department
2801 Atlantic Avenue
Long Beach, CA 90806
Phone: (562) 933-1141
Fax: (562) 933-1185
Hours: 8:00 AM to 4:00 PM

Miller Children's Hospital Long Beach
Medical Records Department
2801 Atlantic Avenue
Long Beach, CA 90806
Phone: (562) 933-1141
Fax: (562) 933-1185
Hours: 8:00 AM to 4:00 PM

Orange Coast Medical Center
Medical Records Department
9920 Talbert Avenue
Fountain Valley, CA 92708
Phone: (714) 378-7440
Fax: (714) 378-7494
Hours: 8:00 AM to 4:00 PM

Saddleback Medical Center
Medical Records Department
24451 Health Center Drive
Laguna Hills, CA 92653
Phone: (949) 452-7050
Fax: (949) 837-4621
Hours: 8:00 AM to 4:00 PM

MemorialCare Medical Group
Medical Records Department
17360 Brookhurst Street
Fountain Valley, CA 92708
Phone: (714) 665-1647
Fax: (714) 665-4681
Hours: 8:00 AM to 4:00 PM