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Medical Records


Release of Medical Records Information (DHMF)

All patients or their legal representatives of Mercy Medical Group (MMG) at Dignity Health Medical Foundation, may obtain and/or review a copy of medical records for personal use, or have copies of their medical records sent to their new healthcare provider. Record’s request made through this website are for clinic records only. 

The Health Information Management Department of Dignity Health Medical Foundation requires patients to complete and sign an Authorization for Release of Health Information form before releasing any documents to another entity, including the patient. 

How to Request Records


Patient Request

If you are requesting records for yourself, please use the below Patient Access form:

Patient Access Form

If you are requesting records to be sent to a third party, please complete the below Release of Information Authorization form.

Authorization of ROI Form

1. Print, complete and sign the Authorization form. 

2. Fax it to: 916.366.3662

    Or email completed and signed ROI form to:
    [email protected]

    Or you may deliver or mail your completed and signed Authorization form to the address
    below:

Dignity Health Medical Foundation
Health Information Management (ROI Department)
3291 Ramos Circle
Sacramento, CA 95827

Business Hours: Mon. – Friday, 8:00 a.m. – 4:30 p.m. excluding holidays.

Map and Directions: 3291 Ramos Circle, Sacramento, CA 95827 - MapQuest


Mental Health, HIV, HBV and HCV Request

Requests must be specifically check marked and signed, if requesting/authorizing the following information: Mental Health or developmental disability treatment records (excludes “Psychotherapy Notes”), AIDS/HIV, Substance abuse treatments, and Fertility Treatment. (A separate Authorization form needed)

HIV, HBV and HCV Authorization

Behavioral Health Complete Authorization


Legal Request

1. Print, complete and sign the ROI Authorization:

     Authorization of ROI form 

2. Fax it to: 916.366.3662

    Or email completed and signed ROI form to:
    [email protected]

    Or you may deliver or mail your completed and signed Authorization form to: 

Dignity Health Medical Foundation
Health Information Management (ROI Department)
3291 Ramos Circle
Sacramento, CA 95827

Business Hours: Mon. – Friday, 8:00 a.m. – 4:30 p.m. excluding holidays.

Map and Directions: 3291 Ramos Circle, Sacramento, CA 95827 - MapQuest


Don’ts

  • Do not send us photographic pictures of Authorization ROI form.
  • Do not use this form for Hospital Medical Record, Medical Imaging, and Billing record.

For Other Records

  • Hospital Record - Contact HIMS Department at 916.854.2000
  • Films and Medical Imaging - Contact Medical Imaging Department at 916.434.7676
  • Billing Records - Contact Billing Department at 916.379.2804

Questions

  • If you have any questions regarding release of Medical Information, please call us at 916.363.4040.

Important Information for Patients to Know

  • A patient can obtain a copy of his/her recent medical record via email. ROI department can provide copies of his/her most recent 2 years’ worth of records via email for no fee (free). It is faster and convenient to patient.

  • Requests must be specifically check marked and signed, if requesting/authorizing the following information: Mental Health or developmental disability treatment records (excludes “Psychotherapy Notes”), AIDS/HIV, Substance abuse treatments, and Fertility Treatment. (Use this form: HIV, HBV and HCV Authorization

  • If you select to receive your medical records electronically, a Release of Information staff member will send you a message through Axway MailGate SC, Dignity Health’s secure emailing services. You will be prompt to create a password in which you can then login and view your message containing a PDF file of your medical records. If you need technical help with password setup, please contact our helpdesk at 1.888.307.0222

  • Health Information Management charges patients $15.00 for more than 20 paper pages, $10.00 for Flash drive, and $15.00 for legal paper record. We only accept checks as a form of payment.

  • No charge applies for records of 2 years that are emailed to you or to your provider for continuity of patient care.
     
  • To minimize cost, please indicate what time period you are requesting, and/or specify which reports are needed.

  • Provide name(s) and the location(s) of your provider(s) on your ROI request.

  • Typically, the last two years of a patient’s records are sent to the new physician. 

  • Please allow us up to 15 calendar days for request to be processed. 

  • A patient can choose to pick up his/her record from 3291 Ramos Circle, Sacramento CA 95827. Patient’s photo ID is required at the time of pick up record.

  • If you find an error that requires correction, please discuss it with your provider or use the form provided below to request a correction/amendment. Please include a copy of the page(s) where the error(s) occur and the completed form. You will receive a written reply within 60-days but for more complex cases, this may be extended an additional 30 days. 

    Request Form of Record Amendment


Thank you for choosing Dignity Health Medical Foundation for your health care needs.