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Medical Records Request

Complete this form to request your medical records.

Complete this form to request your medical records. You will be taken to the payment page once you submit this form.

If requesting medical records from any physician other than Dr. Osborne, please contact the office via the contact form, or by phone at 310-657-0123 to request medical records.
AUTHORIZATION TO RELEASE RECORDS
PLEASE RELEASE THE FOLLOWING MEDICAL RECORDS TO:
Release these records:*
- ALL MEDICAL RECORDS
- RADIOLOGY REPORTS
- LAB REPORTS
- OTHER
WHICH RECORDS WOULD YOU LIKE TO RELEASE?*
Name of party to release to:*
Address of party to release to:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number of party to release to:
Fax / Email Address of party to release to:
PATIENT NAME:*
First Last
PATIENT DATE OF BIRTH:*
Month
Day
Year
LAST FOUR DIGITS OF PATIENT SOCIAL SECURITY NUMBER:
FOR U.S. CITIZENS ONLY
0 of 4 max characters
YOUR NAME:*
First Last
TODAY'S DATE:*
MM slash DD slash YYYY
YOUR EMAIL ADDRESS:*
AUTHORIZATION:*
- I AUTHORIZE RECORDS TO BE RELEASED
PLEASE ALLOW AT LEAST 24 TO 48 HOURS TO EXPEDITE THIS REQUEST. IF THE REQUESTED RECORDS ARE IN STORAGE, PLEASE ALLOW AT LEAST 48 TO 72 HOURS TO EXPEDITE THIS REQUEST. ALL FEES ARE DUE PRIOR TO THE RELEASE OF ANY MEDICAL RECORDS.
OSBORNE HEAD & NECK INSTITUTE
6240 W. Manchester Ave
Los Angeles, CA 90045
TEL: 310-657-0123
FAX: 310-657-0142
Have you been seen at OHNI within the past three years?*
- Yes, I have been seen within 3 years
- No, I have not been seen in 3 years
How would you like your records sent?*
- $0 (No charge) Email
- $0 (No charge) In-office pick up
- $10 Records printed and mailed
- $10 Fax (please provide fax number)
- $10 Retrieval for records more than 5 years old
How would you like your records sent?*
- $25 Email
- $25 Printed for In-office pick up
- $25 Records printed and mailed
- $25 Fax (please provide fax number)
Fax Number:*
Credit Card:*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
CAPTCHA
Total
$0.00

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