This form is used to request copies of medical records. Only patients or their legal representatives may make a medical record request. Therapy West, Inc. may verify your identity/guardianship. All requests are subject to a reasonable fee. Completion of this form authorizes the use and/or disclosure (release) of individually identifiable health information, as set forth below, consistent with California and federal law concerning the privacy of such information. Failure to provide all information requested may invalidate this authorization.
Please note there is a fee. For electronic delivery, it is $25. If you prefer that the medical records are mailed, the fee is $35.