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  • Medical Records Release Iipdf - Longmont Clinic

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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION To Transfer Records From Longmont Clinic to Another Medical Provider Section A . Comp lete for A ll Au thorizations I hereby authorize Longmont Clinic.

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Welfare and Institutions Code section 14124.1 (which relates to Medi-Cal patients) specifies a ten-year retention period. The Knox-Keene Act requires that HMO medical records be maintained for a minimum of two years under Title 28 of the California Code of Regulations (CCR) section 1300.67.

Generally, your health care provider must give you a copy in the format that you request if they are able to do so. Your provider may charge you a fee to get a copy of your record.

By email: PRA@dmhc.ca.gov. By mail: Department of Managed Health Care, attn: Office of Legal Services, 980 Ninth Street, Ste. 500, Sacramento, CA 95814. By fax: (916) 322-9430.

Patients may request a copy of their medical records by completing and submitting an Authorization for Release of Personal Health Information form. Please download and complete the authorization form to submit your medical record request by fax, email or mail. Verification of identity may be required.

Request Records Through MyChart If you are unable to locate the activation code or need assistance, please contact UCM Connect at 1-888-824-0200. Ingalls' records will be available through MyChart beginning with 8/1/2022 visits.

A $20.00 handling charge for processing the request for copies. $0.75 per page for the first through 25th pages.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232