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 (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. Please also note that record pick up will be by appointment only.
   1. If you want the information to be faxed, please provide the fax number.
   2. 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 Medical Records Department.
9. Submit the completed authorization form by fax, mail or email to the appropriate Medical Records Department listed below.

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:

MemorialCare Health System (All Hospitals) 

Medical Records Department 

Phone: (657) 241-7001 
Fax: (657) 276-4774 
Email: MHSHIMMedicalRecords@memorialcare.org 
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: MedicalRecords@memorialcare.org 
Phone Hours: 8:00 AM to 4:00 PM; Monday -Friday (excluding holidays)