Fax, Email, or Mail
Download, print and complete the authorization form.
Patient Request for Medical Records
Release of Medical Records to Others
The authorization form must be signed and dated. In order to verify your identification and validate your authorization, we require a legible copy of a valid photo I.D.
Send the filled, signed, and dated form to the hospital via one of the following methods.
1) Fax the form to (909) 806-1063
2) Email the form to [email protected]
3) Mail the form to the Medical Records Department.
Medical Records Department
1805 Medical Center Dr.
San Bernardino CA. 92411