Services

REQUESTING MEDICAL RECORDS

How to request a copy of your medical records or x-ray and radiology images

I. COMPLETE A RELEASE OF INFORMATION FORM

1. Patients or their legal representatives can get copies of their medical records, or have copies sent to another facility. To do this, O’Connor Hospital requires a completed and signed form before we can release the records to anyone, including the patient.

   Print and complete the Request for Release of Medical Record Information form. This release of information form is available as a Spanish version and a Vietnamese version. (The form must be completed, dated and signed.)

2. Make sure to specify which parts of your medical records you wish to obtain. Often the discharge summary, operative report and history and physical exam have information needed for continued care.
3. Requests/authorizations for the following information must be initiated as indicated on the form by the authorized person:
   • Psychiatric Care
   • AIDS/HIV
   • Alcohol/drug abuse

If you have questions about this process or regarding the release of medical record information, please call (408) 947-4719. For information regarding radiology films or the CD library, call (408) 947-4730.

II. SUBMITTING YOUR REQUEST

Once you have completed your request for release of medical information, you can submit your request by mail or bring in person to the health information management department, or by faxing the form.

Mail or in Person

O’Connor Hospital
Health Information Management Department
Release of Information
2105 Forest Avenue
San Jose, CA 95128

The Health Information Management Services (Medical Records) Department is located on the first floor of O’Connor Hospital, across from the Gift Shop.

Fax

(408) 947-3434
Title Attn.: Release of Information

Hours

Monday - Friday
8 AM - 5 PM
Weekend and Holidays: Closed

If the department is closed, there is a specific mailbox where you can drop off your request by the Medical Record Department door.

Additional Information

• If you plan to have someone else pick up your records, make sure your representative has an original, signed authorization letter from you, as well as a photo ID.
• Please allow up to 10 business days or 14 calendar days for your request to be processed.
• If you indicate that you want to pick up your forms in person, you will be contacted by the Release of Information Office when your records are ready. A photo ID is required.

---

Cost for Copy of Information

Records requested for a physician or other provider are sent to the provider at no cost. If you would like to obtain a copy for your records the following costs could apply:

• $6.50 for a copy of the electronic portion of the record.
• $0.07 per page to reproduce the part of your record that is stored in paper.
• If your charges exceed $100, we may require payment before the records are released

For X-Ray or radiology images, the first CD or set of films is free; additional copies cost $15 for CD, or $15 for each film. To contact the Radiology Film/CD Library, call (408) 947-4730.

---

To Obtain a Copy of Your Birth Certificate

Copies of birth certificates can be obtained through the Clerk Recorder’s Office of Santa Clara County. For more information, please call (408) 299-5688 or visit their website: www.clerkrecorder.org