Your Personal Health Information
If you or your minor child has or is receiving services from Pacific Clinics you may request a copy of the medical record. To request a copy of a minor child’s record you must be the legal guardian.
Your request will be evaluated based on the applicable California Laws and Federal Regulations in conjunction with HIPAA in regard to the release of health information.
To request that we send health information to another health care provider that Pacific Clinics retains on you or your minor child, complete the release of information form below.
Request for Release of Medical Records
Use this form if you want to request the release of medical records.
You can mail or fax your completed request form to the address or fax number below. If you have questions, please contact Privacy Officer Jennifer Cass at (408) 364-4024 or email@example.com.
Send by mail to:
Health Information Management
251 Llewellyn Ave.
Campbell, CA 95008
or send by fax to: (408) 364-7065.