Electronic Health Information Request Form

In compliance with the CURES Act, the form below is intended for entities—or agents acting on behalf of an entity—to submit requests for Electronic Health Information (EHI). Responses to submitted requests will be provided within ten (10) business days. Patients seeking access to their medical records should visit [Medical Records | For Patients].

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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