Electronic Health Information Request Form

In compliance with the CURES Act, the form provided below is for entities or agents representing an entity to submit a request for Electronic Health Information (EHI) . Upon submission, responses to requests will be provided within ten (10) business days.

Note: If you are a patient looking for medical records for yourself or you are a proxy for a patient, please visit our medical records page. If you are a physician needing access to a patient’s record, please contact HIMS.

Please do not include PHI in your form submission.

Information About You

* All fields are required

(Please write “None” if not applicable.)
Do you want the information sent from El Camino Health?

 

Information About the Represented Company

(Please write “Same” if same as company you’re with.)
(Please write “None” if not applicable.)
(Please write “None” if not applicable.)
 

Information About Your Request

 

Allergies and Intolerances - Drug Class
Allergies and Intolerances - Medication
Allergies and Intolerances - Reaction
Assessment and Plan of Treatment
Care Team Member(s)
Clinical Notes - Consultation Note
Clinical Notes - Discharge Summary Note
Clinical Notes - History & Physical
Clinical Notes - Imaging Narrative
Clinical Notes - Laboratory Report Narrative
Clinical Notes - Pathology Report Narrative
Clinical Notes - Procedure Note
Clinical Notes - Progress Note
Patients Goals
Health Concerns
Immunizations
Laboratory - Tests
Laboratory - Values/Results
Medications
Patient Demographics - First Name
Patient Demographics - Last Name
Patient Demographics - Previous Name
Patient Demographics -
Patient Demographics - Middle Name
Patient Demographics - Suffix
Patient Demographics - Birth Sex
Patient Demographics - Date of Birth
Patient Demographics - Race
Patient Demographics - Ethnicity
Patient Demographics - Preferred Language
Patient Demographics - Current Address
Patient Demographics - Previous Address
Patient Demographics - Phone Number
Patient Demographics - Phone Number Type
Patient Demographics - Email Address
Problems
Procedures
Provenance - Author Time Stamp
Provenance - Author Organization
Smoking Status
Unique Device Identifier(s) for patient
Vital Signs - Diastolic blood pressure
Vital Signs - Systolic blood pressure
Vital Signs - Body height
Vital Signs - Body weight
Vital Signs - Respiratory rate
Vital Signs - Body temperature
Vital Signs - Pulse oximetry
Vital Signs - Inhaled oxygen concentration
Vital Signs - BMI Percentile (2 - 20 years)
Vital Signs - Weight-for-length Percentile
Vital Signs - Head Occipital-frontal
Vital Signs - Circumference(Birth-36 Months)
None of the Above
 

Information About Your Legal Authority

Do you have patient authorization or a patient consent form?
Does your organization have a SOC II report or similar third party audit report on Security Controls (e.g., HITRUST Certification)?
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