Medical Records Request Page 2
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3UNIVERSITY OF SOUTHERN CALIFORNIA
ACCESS REQUEST FORM
Patient's Name:
__________________________________________________________
Last
First
Middle
Date of Birth:
__________________________________________________________
Phone Number:
__________________________________________________________
I hereby request that my University of Southern California health care provider(s) provide me with
the following information (check all that apply):
My clinical records (e.g., medical record, dental record)
My x-rays
My billing records
Other _____________________________________________________________________
(Must be personally identifiable information used by USC to make clinical decisions
about the patient)
Please check the boxes that apply:
I am only interested in accessing or obtaining a copy of Requested Information relating to
the time period ________ through ___________.
I am interested in accessing or obtaining a copy of all Requested Information maintained by
(please list the name of your health care provider(s) whose records you wish to access):
________________________________________________________________________________
I agree to receive the Requested Information in the form of a summary prepared by USC at a
cost to me of $____.
Information Excepted from Request
I understand that any information provided to me pursuant to this request will not include
information compiled in reasonable anticipation of (or for use in) a civil, criminal or administrative
proceeding or as may otherwise be limited or restricted by applicable law. If I am a parent or legal
guardian requesting access to a minor’s information, I further understand that I will not be provided
access to records related to certain categories of treatment as required by law (for example, a
minor’s receipt of contraception and/or family planning services).
05.03 (rev.)
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