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

 

 
 

Information About Your Legal Authority

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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