FORMS
PHI Authorization Form:
(Allows us to speak to another person, share information regarding your care, or allow patient portal family sharing)- Form: PHI Authorization Form (Adobe PDF format, 180kb)
- Directions:
- Patient fills out:
- Their own information
- Information for the person they want to receive their information
NOTE: Patient Portal Family Accounts require access to ALL information - The information they want to share
- Patient signs, dates, and returns the form to our office via:
- Email: records@geneseemedical.com
- Fax: 858-268-0761
- Mail: 3800 Murphy Canyon Rd., Suite 120, San Diego, CA 92123
- In person to our front desk staff
Please allow 10 business days for your chart to be updated or portal request to be completed.
- Patient fills out:
Medical Records Release Forms:
(Allow us to send your records to another provider or entity)- Form: Fee Letter (Adobe PDF format, 316kb)
- Form: Release To (Adobe PDF format, 180kb)
- Form: Release From (Adobe PDF format, 180kb)
Directions: Medical Records Release
In order to protect your privacy and ensure compliance with HIPAA requirements, Genesee Medical Group contracts with a professional compliance and correspondence service for the reproduction of medical records.
Records requests are processed once a week, typically on Fridays, and can take up to 5 business days to receive. If you are changing physicians and wish for your new physician to receive a copy of the last two years of your chart, we will provide this at no charge to you. All other patient-initiated requests will be subject to the charges as outlined in the
Fee Letter.
You have the following choices:
- If you would like to have records sent FROM another medical facility or physician, sent TO Genesee Medical Group, you must use the
Release To
form. Please note there may be a cost from the originating physician's office or location. - If you would like to have records sent directly to you or any other entity, you must use the
Release From
form. Please note the cost for available services are outlined in theFee Letter.
For help with medical-records related questions, please contact our Medical Records department at 858-268-1111.
- If you would like to have records sent FROM another medical facility or physician, sent TO Genesee Medical Group, you must use the
U.S. Citizenship and Immigration Services (USCIS) Form I-693:
- Form: http://www.uscis.gov/sites/default/files/files/form/i-693.pdf (Adobe PDF format, 1.1MB, revised 10/19/2017)
- Directions: http://www.uscis.gov/sites/default/files/files/form/i-693instr.pdf (Adobe PDF format, 394kb, revised 10/19/2017)
- For more information about the I-693 form, see: http://www.uscis.gov/i-693