OSBORNE HEAD & NECK INSTITUTE 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. YOUR PHYSICIAN:* Dr. Ryan F. Osborne Dr. Raphael Nach Dr. Hootan Zandifar Dr. John Rehm Dr. Jason S. Hamilton Dr. Ronen Nazarian Dr. Michael Godin Other AUTHORIZATION TO RELEASE RECORDSPLEASE 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 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 ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name After submitting this form, please call the office at 310-657-0123 to make payment for your medical records request.Medical Records Payments* I understand that must call OHNI to make a payment for this request. 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