Medical Records Request

As a patient of the Association of South Bay Surgeons, you are entitled to view and/or
receive copies of your medical records. In an effort to facilitate this process, please
download and complete our HIPAA compliant authorization form, which allows us to
release information contained in your medical record.

To Request Copies of your Medical Records:

1.    Please print the Authorization to Release Medical Records form.
2.    Complete this form in its entirety, including your name, date of birth and email address. Please provide us with a detailed description of the information you are requesting as well as a complete mailing address and phone number for the individual(s) who will be receiving this information.
3.    Please provide an expiration date for this authorization. Make sure that you sign and date the authorization form.
4.    Completed authorizations can be submitted via:

Mail:
23451 Madison St., Suite 340
Torrance, CA 90505

Fax: 424-263-2415, Attn: Medical Records Department

E-Mail: Please scan your completed authorization with your
signature and email as an attachment to ana@southbaysurgeons.com

Please allow 5-7 business days for processing. Please contact the Medical Records
Department at 310-373-6864 option 6 or email at ana@southbaysurgeons.com with any questions.

Thank you.