Genesee Medical Center in San Diego

photo of medical 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)Get Adobe Reader
  • Directions:
    1. 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
    2. Patient signs, dates, and returns the form to our office via:
      • Email:
      • 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.

Medical Records Release Forms:

(Allow us to send your records to another provider or entity)
  • Form: Fee Letter (Adobe PDF format, 316kb) Get Adobe Reader
  • Form: Release To (Adobe PDF format, 180kb) Get Adobe Reader
  • Form: Release From (Adobe PDF format, 180kb) Get Adobe Reader
  • 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 the Fee Letter.

    For help with medical-records related questions, please contact our Medical Records department at 858-268-1111.

U.S. Citizenship and Immigration Services (USCIS) Form I-693:

More forms coming soon.

Other Documents