⇝ Patient Request
Bergey Spine Institute, will not release your Protected Health Information (PHI) to you or to your designated representative without your written authorization, except as required or permitted by law.
If you need to request your records, please download, fill out and sign any of the forms provided below.
Once you have completed the request form, mail or email it to:
- 1142 S. Diamond Bar Blvd #310, Diamond Bar, CA 91765
OR speed up the process by submitting our online request form. Please note that an email address is required, without a valid email address your digital request for records cannot be processed.
Frequently Asked Questions
Unfortunately, most healthcare professionals have been forced to deal with attorneys and third party requesters that misuse HHS/OCR guidance on the Patients’ Right to Access rule in order to obtain copies of their clients’ medical records for litigation purposes at the nominal rates allowed under the Privacy Rule. The Right to Access clause does not specify, nor allow patients, attorneys, or third-party requesters to receive an executed Custodian of Records Affidavit —that is only intended for litigation purposes.
To obtain a copy of your protected health information, you will need to fill out our release of information form. Please download a copy from any of the links provided above. The completed form can be fax or email to email@example.com.
To download copies of your medical records, you must sign in to your secure online account. If you need help resetting your password, we can help by sending you a link to reset it. Please, click on the following link.
Accounts that are inactive, will move to inactive status after ninety 90 days and will not be accessible to the end-user. To resolve this issue, please contact us by email at firstname.lastname@example.org
Due to patient confidential and information security issues we do not accept telephone requests. We need a written and signed authorization to release protected health information.
To expedite the process of your request for records, please sign up by clicking on the above link. As soon as your complete registration is received, we will contact you and provide all the information necessary to retrieve your records.
Yes. If you specify in writing on your authorization release form, we can also submit digital copies of your health information to your legal counsel, claims adjuster, or disability evaluator analyst.