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:
- Download the Consent to Release Confidential Client Information
- Sign and date the Consent to Release.
- Take a photo or scan both sides of the completed Consent to Release.
- Fax or email along with a photo of your California ID or DL (see fax #/email below).
- 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 408.624.6073.
Completed forms can be mailed to:
Momentum for Health
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