Are you interested in printing or viewing your laboratory results, radiology reports and a summary of your immunizations, medications and allergies? This option is free and available 24/7 on the Patient Portal.
If you would like to request a physical copy of your medical record from Health Information Management, please download an Authorization for Release of Health Information below. An Authorization for Release of Health Information is required for any use
or disclosure of Protected Health Information (PHI).
The patient must sign the authorization unless the patient is a minor or declared physically or mentally incompetent. If the patient is a minor, one of the patient’s parents would sign the authorization. If the patient is mentally or physically
incompetent the patient’s legal guardian would sign the authorization and provide a copy of the Durable Power of Attorney of Health Care. If requesting records on a deceased patient, please see requirements on the Authorization for Release of
Mail or fax the completed form to the Health Information Management office. You may also complete the Authorization for Release of Health Information form in person at our office during business hours. Hours of operation are Monday through Friday 8:30
– 4:30 pm. Closed weekends and holidays.
Please note: Unsigned and/or incomplete requests cannot be processed.
How can my physician obtain my medical records?
Your physician may fax a request to our department to request your health information for treatment. You may also complete an Authorization for Release of Health information and submit it to the Health Information Management office with your physician’s
How can I obtain my Radiology Imaging?
To obtain a copy of your Radiology Images on a CD in addition to requesting printed medical documents, please check the box “Other” and write “include imaging on CD” on the line next to it. Health Information Management will process
your record request and submit your CD request to the Radiology Department for processing.
To ONLY obtain a copy of your Radiology Images on a CD (no other printed medical documents are needed), please print and complete an Authorization for Release of Health Information form. Check the box “Other” and write “imaging on CD”
on the line next to it. Please contact the Radiology Department Monday through Friday 7:30 am – 4:00 pm for processing.
Yes. There is a 25¢ per page copying fee, plus postage. Our copy service, CIOX, will process your medical record request. If you would like your physician to receive your records for follow-up care, please provide the physician’s fax number on your authorization form. There will be no charge for records to be sent to your physician.
Yes. Please indicate on the Authorization for Release of Health Information request form that you would like to pick your records up in person. For your protection we require picture identification before releasing copies of your medical records.
Twin Cities Community Hospital Health Information Management 1100 Las Tables Rd, Building 1220 Suite 1427, Templeton, CA 93465 Office (805) 434-4516 Fax (805) 434-4586 Email: firstname.lastname@example.org