Medical records are official records of Valley Presbyterian Hospital activity
and are considered the property of Valley Presbyterian Hospital. You have
the right to obtain a copy of your medical records, but to protect your
privacy we must have your written permission before releasing the records.
Authorization to Release Protected Health Information form. Click here to download in English.
Click here to download in Spanish. Instructions are below to help you complete the
form, and the Health Information Management staff also is available to
assist you in submitting your request.
Incomplete forms may be returned to you for completion. By law, no information
can be released unless the form is properly signed and appropriate proof
of identity is supplied.
General information:
Valley Presbyterian Hospital
Health Information Management
15107 Vanowen Street
Van Nuys, CA 91405
Phone: 818.902.2939
Fax: 818.781.0429
Hours of operation:
Monday-Friday, 8:00 AM - 4:30 PM
Step 1
Download, print out and complete an Authorization to Release Protected
Health Information form. (See English or Spanish links above to download.)
Other options are to stop by the Health Information Management Department
and fill out a release there, or call 818.902.2939 to request that a copy
of the release form be mailed or faxed to you.
Step 2
Bring the completed form to the Health Information Management department.
Or, you may mail or fax the completed form
with a readable copy of your driver's license. (Our address and fax number are listed above.)
Valid Authorization:
The authorization must include the following information to be valid:
- Patient's Full Name (including any former name)
- Patient's Date of Birth
- Name and address of the patient or authorized representative to release
- Name and address of the person/entity receiving the information
- Date(s) of treatment or service needed
- Specific information to be released (i.e. lab report)
- Purpose for which the information may be disclosed (continuing medical
care, insurance, personal use, and legal)
- Expiration date when the authorization is no longer valid
- Dated and signed by the patient or an authorized representative
Specific Requests
For Copies of an Entire Chart
There are fees involved when copying an entire chart. The process for handling
a request for an entire chart is as follows:
- All requestors must provide a completed authorization and photo ID.
- The number of pages in the chart will be counted and the fee for copying
the chart is calculated based on the number of pages in the chart. Cost
to copy a chart is 25 cents per page. You will receive an invoice for
the total amount before the copy is released.
- Once payment is received, the chart will be sent to you by our copy service.
Records will be mailed to the address specified on the authorization form,
or you may pick them up at our office if you make arrangements with the
Correspondence Staff. For security reasons, please be prepared to show
proper photo identification.
- Requests are usually completed within 14 business days from the time of
the initial request. We will contact you in the event we experience unforeseen
delays or are unable to fulfill your request.
For Copies of Specific Documents in the Chart
There is no fee for the first-time request by the patient for copies of
individual tests or documents up to and including 10 pages of information.
There will be a charge of 25 cents per page for 11 or more pages of information.
- Provide the completed authorization form to Health Information Management.
(Please note, submitting an incomplete form may limit our ability to honor
your request.)
- A member of the Health Information Management staff will complete your
request (make the copy or copies that you requested).
- Records will be mailed to the address specified on the authorization form,
or you may pick them up at our office if you make arrangements with the
Correspondence Staff. For security reasons, please be prepared to show
proper photo identification.
Requests for Continuing Medical Care
Medical emergencies will be faxed free of charge directly to a physician
or medical facility. Continuing care requests are also free of charge
and will be mailed to your clinic/physician(s) prior to your appointment.
Please indicate the date of your appointment on the authorization form
so the copies are received early enough for your physician to review them.
Please ask your physician/clinic to fax a request to Health Information
Management department.
Information such as radiology/imaging, history and physical, consultations,
operative reports, and discharge summaries are routinely provided to the
physician for continuing care.
Sensitive Information
Certain information requires a special authorization covering sensitive
information. This includes psychiatric, drug and/or alcohol abuse, HIV/AIDS,
and genetic testing. Authorizations for sensitive information must specifically
refer to the information that is to be released.
Requests for Medical Records of Deceased Patients
Requests for medical records of deceased patients require a copy of evidence
of next of kin, or executorships of the estate. Please also include your
phone number in case we need to contact you for additional information
concerning your request.
Requests for X-ray Images
Health Information Management does not have access to the actual imaging
study, although we can provide a copy of the report related to your study.
You will need to submit the Authorization to Release to Radiology form.
Radiology & Imaging Services will provide the requested images/CD.
Requests for Birth Certificates/ Death Certificates
Requests for certified copies of Los Angeles Country's Birth or Death
records can be made at Los Angeles County Registrar-Recorder-County Clerk Offices:
Headquarters:
12400 E. Imperial Highway, Room 1002
Norwalk, CA 90650
Phone: (562) 452-2137
Phone: (562) 452-2116 (credit card order only)
Van Nuys:
14340 West Sylvan Street
Van Nuys, CA 91401
Phone: (818) 374-7176