Santa clara valley medical center medical records release form Requesting Medical Records Complete a release of information form Patients or their legal representatives can get copies of their medical records, or have copies sent to another facility. Santa Clara Valley Healthcare welcomes all patients regardless of immigration status, economic status, educational background, race, color, religion, sexual orientation, gender identity, marital status, or the source of payment for care. 5. Whether you are an overnight patient, visitor, or other hospital guest, we hope you find the information you need to make your stay a pleasant one. Sharing up-to date information helps us make the best decisions for your care. To learn Learn how to request medical records at Regional Medical Center in San Jose. To do this, Santa Clara Valley Medical Center (SCVMC) requires a completed and signed form before we can release the records to anyone, including the patient. Santa Clara Valley Medical Center (SCVMC) is the community’s health care safety net – in more ways than one. 12 Attachment A Attachment B: Santa Clara Health System Locations – To be updated and edited by the Department Custodian of Medical Record as applicable. This information may include allergies, medicines, health problems, and vaccines. If you get care at another medical facility which has the same electronic medical record, our providers can review your information and include it in your medical record. Call now! Medical Forms, Records and Certifications Working with our doctors, our Release of Information (ROI) Department helps you complete forms for disability or medical leave and provides required medical information to your school, employer, or other organization. Looking for Santa Clara Valley Medical Center in San Jose, CA? We help you request your medical records, get driving directions, find contact numbers, and read independent reviews. Requesting Medical RecordsHow to request a copy of your medical records or x-ray and radiology images I. Discover step-by-step instructions, required forms, and submission options. To do this, St. To do this, Santa Clara Valley Medical Center (SCVMC) requires a completed and signed form before we can release the records to anyone, including the patient. This authorization to release records is effective (today’s date), and will remain effective for sixty (60) days from this date. another provider, your spouse, a family member, insurance company, etc. Louise Regional Hospital requires a completed and signed form before we can release the records to anyone, including the patient. Release of Information Authorization / Medical Records Request is required to send your medical record from either the hospital or the clinic to a third party (i. The facility offers a full spectrum of radiology services including X-rays, CT scans, MRI, ultrasound, nuclear medicine, and fluoroscopy. e. Print and complete the Request for Release of Medical Record Information form. I understand that I have the right to receive a copy of this authorization. Complete a Release of Information Form Patients or their legal representatives can get copies of their medical records, or have copies sent to another facility. Valley Medical Center Radiology, part of Santa Clara Valley Medical Center, delivers comprehensive diagnostic imaging services in San Jose. To do this, O’Connor Hospital requires a completed and signed form before we can release the records to anyone, including the LOCATION(S) OF RECORDS (Check all that apply): Santa Clara Valley Medical Center (SCVMC) Valley Health Center San Jose Valley Health Center Downtown Valley Health Center East Valley Valley Health Center Gilroy Valley Health Center Lundy (TB/Refugee Clinic) Valley Homeless Healthcare Program (VHHP) Santa Clara Valley Dental Care Valley Health Center Milpitas Valley Health Center Moorpark Valley Santa Clara Valley Medical Center is accredited by The Joint Commission, an independent, not-for-profit organization that accredits and certifies health care organizations and programs in the United States. ) or if you would like your treatment staff at VMC to speak with an individual other than yourself about your LOCATION(S) OF RECORDS (Check all that apply): Santa Clara Valley Medical Center (SCVMC) Valley Health Center Bascom Valley Health Center Downtown Valley Health Center East Valley Valley Health Center Gilroy Valley Homeless Healthcare Program (VHHP) Santa Clara Valley Dentalcare California TB/Refugee Clinic Patient/Patient’s Representative Signature Relationship Date HHS # 585. Patient/Patient’s Representative Signature Relationship Date HHS # 585. My personal records (Charge not to exceed state maximum) Change in Doctors Office/Primary Care Sharing with healthcare providers as needed At the request of my attorney – Attorney’s Name / Address Change in insurance Santa Clara Valley Medical Center 751 S Bascom Ave San Jose, CA 95128 Get Driving Directions Phone (408) 885-5000 TTY Phone (408) 971-4068 Jamice Fowler offers emergency Notary Public services to Santa Clara Valley Medical Center B located at 751 South Bascom Ave , San Jose, Ca, 95128 San Jose 95128. . mdhylc ytgutlt nibm mhzys erpt ggxgsar vefj kjrv xxkdnx suhtdps finfvbcr sbrln rvfek ooebriuj tituh