Request for Medical Records To Us

Prime Wellness Community Health Center

8610 S Sepulveda Blvd Ste 104, Los Angeles, CA 90045

📞 Phone: (310) 659-7867| 📠 Fax: (310) 878-2118

Name/Clinic (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Patient Name (Last, First) (required)

Date of Birth (required)

Name of Parent or Legal Guardian (if minor)

Address

City

State (required)

Zip Code

Home Phone Optional - Format: 123-456-7890 or (123) 456-7890

Please enter a valid US phone number.

Work Phone Optional - Format: 123-456-7890 or (123) 456-7890

Please enter a valid US phone number.

Please specify records to be released (required)

Signature (required)

Date (required)

Note: This authorization will expire one year from the date signed.