Medical Records

Completing an Authorization Form

The Health Insurance Portability and Accountability Act, also known as HIPAA, requires hospitals to obtain an original, complete, and properly executed “Authorization for Use or Disclosure of Protected Health Information” form in order to provide a copy of a patient’s medical record to a patient or anyone she or he designates. Only the patient, parent/legal guardian, or the patient’s legal health care representative can sign the form to release medical records.

The authorization form must be legible and complete. Authorizations that are illegible or incomplete will be returned. Requests for information regarding any of the following items must also be specifically initialed on the form:

• AIDS/HIV
• Chemical Dependency
• Mental Health

During COVID-19 please call us and we will mail an Authorization to you or you may pick up a form from the Receptionist in the Front Lobby. You can also access the Authorization form at the links below.

Submitting The Authorization Form

Once your “Authorization” form is completed, you may submit your request by mail, fax, or in person.

Fax

(213) 537-0961

Mail or In Person
Memorial Hospital of Gardena
Attn.: Health Information Management Department
1145 W. Redondo Beach Blvd.
Gardena, CA 90247

Fees

Records released to a Physician’s Office or a Medical Facility are free of charge.

Billing Information

Please note that your medical records do not contain any billing information. For questions about your Memorial Hospital of Gardena’s bill, please call the Central Business Office at (562) 968-5600.

On behalf of Memorial Hospital of Gardena, we sincerely appreciate serving you. We deeply value your relationship with Memorial Hospital of Gardena and we are committed to providing you with the highest level of service because our customers deserve the very best.