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Medical Records Request: Primary Care and Referring Providers Only

This form is for primary care physicians (PCPs) and referring providers only. Use it to request records for your patients, up to 20 patients at a time. Fields marked * are required.

Not the patient’s primary care or referring provider? Use the third party request form on the Medical Records Request page instead. Patients can request their own records there too.

Records are only sent if the requesting provider is the patient’s referring provider or primary care physician (PCP) on file. We compare the provider you enter below with what is on file for each patient. If it doesn’t match, we can’t send that patient’s records.

Requesting provider

Enter your clinic or practice, the provider’s name, or both. The provider’s name is optional if you enter a clinic or practice.

Start typing the clinic or practice name to search the public NPI Registry. Matches nearest to our office (Temple City, 91780) are listed first, and picking one fills in the clinic’s NPI, address, phone, and fax.

Start typing the provider’s name to search the public NPI Registry for physicians, nurse practitioners, and physician assistants, nearest first. Picking one fills in the name, NPI, address, phone, and fax. You can edit anything afterward.

Clinic or provider’s address

Patients

Add each patient whose records you need. You can add up to 20 patients in one request. For more, send a second request.

Records requested
Types of records being requested
How do you want to receive the records?

Fax requires a fax number above. Email goes to the address above.

Submitted by

Submitted securely to our office. Do not use this form for emergencies. Questions? Call 626.898.4560.