Medical Records Authorization: Providence Little Company of Mary - San Pedro Medical Center
Please submit your forms by fax
We're asking for your help to reduce the amount of paper requests we receive. Please refrain from submitting your forms by mail. Instead, please fax them to 310-514-5404. Thank you.
Providence is required by law to maintain the privacy of your health information, to provide you with a notice of our legal duties and privacy practices, and to follow the information practices that are described in the Notice of Privacy Practices.
You have the right to receive a copy of your health information that we maintain, with some limited exceptions. You have the right to receive a copy of your health information in a format you prefer (e.g., paper, email, CD, fax, MyChart). You have the right to request that your health information be sent to any person or entity.
Obtain your medical records via MyChart
Patients can obtain copies of electronically-maintained records at no charge directly from your MyChart account. The MyChart secure web portal allows patients to view portions of their medical record, send a message to their care team, view and pay bills, and request copies of medical records.
To sign up for a MyChart account, visit MyChart.
Request access, authorize disclosure via forms or in writing
To receive a copy of your health information, you may complete the Patient Request for Access form, you may write a letter, or if you prefer, you may use the Authorization for Disclosure form:
Formularios para autorización para liberar información de salud
- Autorización para usar o divulgar información médica protegida
- Solicitud del paciente para acceder al conjunto de registros designado
If you choose to write a letter, it must include the following required elements:
- Signed by the individual (patient)
- Clearly identify the patient, preferably name and date of birth
- Clearly identify the person designated to receive the records
- Identify what records are to be included
How to submit your request
For hospital records:
Providence Little Company of Mary San Pedro
Attn: Release of Information
1300 W. 7th St.
San Pedro, CA 90732
ROI phone: 310-514-5260
ROI fax: 310-514-5404
Radiology phone: 310-514-5245
Radiology fax: 310-514-5203
For clinic records:
Subpoenas/audits: Please mail request to 3460 Torrance Blvd., Suite 310, Torrance, CA 90503
All other requests: Please submit request directly to the clinic where patient received care.
Please allow sufficient time for processing. Turnaround time is up to 15 days according to California state law.
For medical use, there is no fee if records are to be sent directly to a doctor or other healthcare provider for the purpose of continuing care.
For copies for patients or their representatives, there may be a reasonable, cost-based fee.
For copies for other uses, the current rates set by state law may apply.
Please follow the payment instructions on the invoice you receive with the records.
You may write a letter or complete this form to request a correction to your protected health information that was originated or created by a Providence physician.
Accounting of disclosures request
You may write a letter or complete this form for an accounting of disclosures of your protected health information by Providence Health & Services.
Restriction or revocation request
You may write a letter or complete this form to restrict the release of your protected health information, revoke a previously signed authorization, or to opt out of Care Everywhere.
Providence provides free language services to people whose primary language is not English.