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HEALTH INFORMATION MANAGEMENT

Requests for Medical Records

To begin the process of obtaining copies of your medical records, please print and complete the form entitled "Patient's Request for Access to Protected Health Information."

If you need to have copies of your record released to another individual or hospital, please print and complete the form entitled "Authorization for Use or Disclosure of Protected Health Information."

In order for Health Information Management to process your request, all information requested must by provided.

Please fax your completed form(s) to (626) 457-4791 or mail to:

San Gabriel Valley Medical Center

Health Information Management Department

438 W. Las Tunas Drive

San Gabriel, CA 91776

If you are unable to print the above forms, please call the Health Information Management Office at (626) 570-6630.

Once your request is received by Health Information Management, it will take five days for processing. Your health information will be mailed to you unless arrangements are made to pick up your copy.

Medical records will be faxed or mailed to another hospital or physician's office if requested by a completed Authorization for Use or Disclosure of Protected Health Information.

Records from the Behavioral Medicine Center are released with authorization by the attending psychiatrist.

A spouse, relative or friend cannot obtain a copy of your medical records, or pick up records for you, unless the individual has Power of Attorney for Healthcare Decisions for you. A copy of the Power of Attorney for Healthcare Decisions must be included with your request.

The pertinent part of the medical record is available to patients at no charge. This includes the discharge summary, history & physical, consultations, procedural reports, radiology (diagnostic imaging) and laboratory reports. For copies of additional portions of the medical record, a fee of 25 cents per page will be charged to you. A bill may be mailed prior to the records being copied and sent to you. Money orders will be accepted via mail made out to San Gabriel Valley Medical Center . There is no charge if the copies of the records are sent to physicians for your follow up care or treatment.

Birth Certificates

Birth certificates are processed by the Health Information Management Department and sent to the State of California . San Gabriel Valley Medical Center does not issue birth certificates.

If the child is under one year of age, you may request a copy from the Los Angeles County Vital Records Birth Registrar's Office (Vital Records Office) located at 313 North Figueroa Street : Room 1, Los Angeles, CA 90012 . The phone number for the Vital Record's Office is (213) 240-7812. Information can be obtained on their website at www.publichealth.lacounty.gov. The current fee for a birth certificate is $23.00.

If you cannot apply in person, you may request an application in writing. Send a letter with your name, your baby's name, date and place of birth to the above address. You will need to send a notarized statement with the application and the fee (check or money order to the Department of Health and Human Services) to the above address.

If the child is over one year of age, a copy of the birth certificate can be requested from Los Angeles County Registrar Recorder. Please send address your request to: Attention: Birth Certificates, 12400 E. Imperial Highway , Room 1002, Norwalk, CA 90650 , the website is www.lavote.net. For more information, contact the Recorder's Office at (562) 462-2137.

Death Certificates

Death certificates are not issued by the hospital. Information on obtaining death certificates may be obtained from www.lavote.net. The fee is $16.00 and pertains to County Deaths only from the year 1877 forward.