( Note: Please speak to an ROI specialist for additional information.) You may also request that a summary of your visit(s) be provided for certain applicable fees.Additional charges may apply for electronic processing. Following personal inspection of your health records, should you wish to have copies made, you may ask for them in hardcopy, CD, DVD or other available electronic format.ROI will try to conform with the details of your request but will not provide any guarantee. You may obtain a paper-based copy of your medical record according to your specification.Please call (805) 692-6435 and an ROI specialist will assist you as well as guide you during your appointed time. You may request to inspect your own protected health information in person.Signature of requestor (patient or patient representative) and date signed.inspection, copies, summary, transmission to another provider) What kind of access is being requested (e.g.Record type description and time period of documents requested.Pueblo Multi-Specialty, Lompoc Multi-Specialty, etc. Date of request and Clinic location visited (e.g.In you are unable to obtain a copy of the “Request for Access” form, you may also write a brief letter and include the following information: Sansum Clinic:ĭownload: Authorization for Use/Disclosure of Protected Health Information (English)ĭownload: Authorization for Use/Disclosure of Protected Health Information(Español) Ridley-Tree Cancer Center:ĭownload: Authorization for Use/Disclosure of Protected Health Information(English) There is no charge for forwarding health information to other providers including those outside Sansum Clinic. Release of patient medical information requires completing an “Authorization for Use/Disclosure of Protected Health Information” form. ![]() This form, which is also available in Spanish, is necessary for the inspection or copying of a patient’s medical records. To begin the process, obtain a “Request for Access to Protected Health Information” form from the Sansum Clinic Release of Information Department (ROI) fill it out completely and return to ROI (a) in person, (b) via fax (ROI Fax Number: 80), or (c) by mailing the signed and dated form to:ĪTTN: HIS Release of Information has moved! Out of the Pueblo basement and into bright and spacious offices at 89 South Patterson, on the corner of Debbie Road and South Patterson (across from Sansum Clinic Goleta Family Practice). Telephone or email requests are not valid and are not accepted. How to Access Your RecordsĪll requests for access are required to be in writing. These records, however, remain the property of the Clinic, and we are obligated to ensure their integrity to manage and safeguard them in support of services rendered to our patients and to provide documents pertaining to those services when necessary for continuity of care. Patients gain access to their individual records by inspecting them privately in person, by obtaining copies, by receiving a summary report, and by having them forwarded to another provider.Īs stored and maintained by Sansum Clinic, health records are accessible in both their paper-based and electronic formats. ![]() The Clinic provides such access in various ways, although it may be denied in certain specific cases and for legitimate reasons. As a Sansum Clinic patient, you may rightfully access your own health records with but a few limitations. Access Your Medical Records It’s Your Right by LawĬalifornia law and Federal HIPAA regulations guarantee access rights to medical records and other protected health information.
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