Request for Records Release

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Santa Monica Pet Medical Center
Authorization For Release Of Medical Records

Requester Notice

CA Health and Safety Code ss1795.12

“…Any patient’s representative shall be entitled to copies of all or any portion of the patient’s records which he or she has a right to inspect, upon presenting a written request to the health care provider specifying the records to be copied, together with a fee to defray the cost of copying, which shall not exceed $0.25 per page.  The health care provider shall ensure that the copies are transmitted within 15 days upon receiving the request.”

 

As a courtesy to you, there is no charge for copies of records to be sent to another veterinarian for continuing care.  For any other purpose, there is a pre-payment of $5.00 payable to Pet Medical Center.

 

If records are to be mailed, there is an additional $5.00 charge.

 

An invoice for the balance will be sent to you after the records are copied. 

 

Upon receipt of full payment, the records will be forwarded to you.

 

By clicking on the "SUBMIT" button below, you acknowledge having read and understood this notice.


Pet Medical Center Only

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