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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:

Section 1: Enter the patient information: legal name, date of birth, address, phone, last four digits of your Social Security Number.

Section 2: Location of treatment: name of physician, clinic, or hospital where patient was treated (include address, phone number, fax number).

Section 3: Where and to whom records are sent: name of person, physician, or hospital where records are going to (include address, phone number, fax number).

Section 4: Reason for requesting records: check the appropriate box.

Section 5: Provide dates of treatment being requested and check the appropriate box(es) for records needed. 
**Pertinent information includes doctors’ notes and test results.

Section 6: If you need imaging, please indicate which type of imaging is needed.

Section 7: Authorization for specific sensitive information: HIV Results, Genetic Tests, Psychiatric Therapy Notes, Alcohol and/or Drug Abuse Program Treatment Notes. You must also sign this section specifically to receive this information.

Section 8: Delivery Preference: choose how you would like to receive your records. Please note the processing cost for records issued for personal use is $0.25 per page for paper copies and $6.50 per CD or USB.

Section 9: Expiration date: if another date is not provided, the authorization is only valid for ninety (90) days. This section requires that you provide your initials in the space provided.

Individual Rights: Outlines your Individual Rights as they pertain to this authorization. 

Signature / Date / Time: In order to process your request, this section must be completed. 

**Please note that incomplete forms may cause a delay in processing your request** 

Submit the completed form by fax, mail or email to the appropriate Medical Records Department listed on the form or at the bottom of this page.

Introducing Our New All-in-One Requester Portal:

Requesting medical records just got faster. Designed for attorneys, health plans, researchers, and authorized representatives, our new portal consolidates your entire medical records request workflow into one seamless platform.

What you can do in the new portal:

  • Manage Your Profile: Easily save and update your requester information.
  • Streamline Authorization Submissions: Download official authorization forms and upload them alongside up to five supporting documents (e.g. Photo ID).
  • Submit & Track Requests: Enter patient details and submit requests directly to specific hospital locations.
  • Pay & Download: Securely pay for and download records as soon as they are processed by our release clerks.

Select Your Location & Get Started

How to Opt-out of the Health Information Exchange:

Complete the "Patient Opt-Out Request" form:

  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:

MemorialCare Health System (All Hospitals) 

Medical Records Department 

Phone: (657) 241-7001 
Fax: (657) 276-4774 
Email: [email protected] 
Phone Hours: 8:00 AM to 4:00 PM; Monday -Friday (excluding holidays) 

MemorialCare Medical Group 

Medical Records Department 

Phone: (714) 665-1647 
Fax: (714) 665-4681 
Email: [email protected] 
Phone Hours: 8:00 AM to 4:00 PM; Monday -Friday (excluding holidays)