Medical Records Requests

Momentum for Health is not able to release your medical records to you or your designated representative without your written authorization, except as required or permitted by law. At this time, this form does not accept electronic signatures so it will need to be printed and completed, including signature and date.

To request a copy of your Momentum medical record:

  1. Download the Client Request for Information.
  2. Sign and date the Client Request.
  3. Take a photo or scan both sides of the completed Client Request.
  4. Fax or email along with a photo of your California ID or DL (see fax #/email below).
  5. Alternatively, send the completed form by mail to address below.

We will then be able to process your request.

NOTE:  This request may take up to 15 calendar days to complete. If there is a delay beyond the 15 days, the QI department will contact you.

If you have any questions regarding the release of your medical records from Momentum, you may contact our Quality Improvement Department at 408-642-6073.

Completed forms can be mailed to:

Momentum for Health
Medical Records
1922 The Alameda, Suite 214
San Jose CA 95126

You can also fax the completed request to 408.642.6076 or email the form to MGraff@momentumforhealth.org

Internal Complaint/Grievance Form

Your feedback is important to us, and we are committed to providing the best possible care and
service to all our clients. If you have experienced dissatisfaction or have concerns regarding the
quality of care or services you have received at Momentum for Health, we would like the opportunity to address and resolve them. Your input is invaluable in enhancing our services and ensuring that we are effectively meeting the needs of the community we serve.

You are not required to use this form to file a grievance or complaint. If you prefer, you may submit
your concerns using the following methods:

• In Person: Momentum for Health, 1922 The Alameda, San Jose, CA 95126
(Alternatively, you may deliver it to any Momentum location)
• By Phone: (408) 261-7777
• By Mail: Attention: Quality Improvement Department, 1922 The Alameda San Jose, CA
95126
• By E-mail: feedback@momentumforhealth.org

 

Client information:

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Name
I hereby attest that the information provided in this grievance form is true and accurate to the best of my knowledge. By submitting this form, I acknowledge that I am filing a formal grievance and authorize the appropriate parties to investigate and address the concerns outlined herein.