Medical Records Request

We are here to support you with your medical records and strive to fulfill your request timely while ensuring your privacy according to the HIPAA Privacy Rule (the Privacy Rule). The following information will help guide you in the options available and contact information if you have any questions.

Obtaining Patient's Medical Records

Please follow the instructions using the links below:

Step 1: Download and print the authorization form for Use or Release of Health Information for the Patient or a third-party (i.e. Healthcare Provider, Insurance Company, Attorney, etc.).

*Form Download: Authorization for Use or Release of Health Information

Step 2: Complete and sign the form. (Please Note: electronic signatures are not accepted at this time.)

Step 3: Submit the completed form via email or mail.

Email: mercy@lifegivingacupuncture.com

Mail: Life Giving Acupuncture Inc.

26700 Towne Centre Dr. Suite 250

Foothill Ranch, CA 92610

Medical Records Processing Fee (Non-Patient/ Third Party Requesters)

We will invoice you for the processing service labor and production of the records and will invoice you by mail/email. We accept checks and/or money orders by mail. Please make checks payable to "Life Giving Acupuncture Inc".

Please note:

Unsigned and/or incomplete requests will NOT be processed and will be returned to the requestor!

We strive to meet a 14 business days turnaround time from the date of receipt of your request and signed form, but please allow up to 3o days for processing as permissible under HIPAA.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

To protect our patient’s confidential medical information we must have valid, complete, and legible authorization to disclose their health information. All sections of this authorization must be completely filled out before Life Giving Acupuncture Inc is permitted to disclose your protected health information.

Notice

Life Giving Acupuncture Inc. and many other organizations and individuals such as physicians, hospitals, and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

Revocation

A patient may revoke this authorization at any time, provide that the patient does so in writing and submit the document to:

Life Giving Acupuncture Inc.

26700 Towne Centre Dr. Suite 250

Foothill Ranch , CA 92610

The revocation will take effect when Life Giving Acupuncture Inc receives it, except to the extent that Life Giving Acupuncture Inc or others have already relied on it.