The Marin Community Clinics’ Health Information Management Systems (HIMS) Department is committed to respecting and protecting the rights of our patients and families. The Health Information Management staff is responsible for the maintenance and confidentiality of all patient records. Any patient over the age of 18 or his/her legal representative has the right to request a copy of their medical records. Please note that HIMS cannot interpret what the information means or discuss it with you.
If you have additional questions after reading the information below, you may leave us a message at 415-798-3124 and one of our HIMS staff members with return your call.
Marin Community Clinics requires an Authorization for Release of Health Information form signed by the patient or legal guardian before releasing records to anyone, including the patient. In certain cases, a patient’s provider, psychologist, or social worker may also be required to approve a request.
How to request a copy of your medical/dental records: Please specify if you would like to pick up the copies in person (at your local clinic) or have us mail them to you. We encourage you to sign up for MCC Connect where you can safely receive an electronic copy of your records.
- Print and complete the Authorization for Release of Health Information form (English / Spanish) , bring it with you to the Medical Records Department at your home clinic or you can mail it to the address below.
- To expedite the process, you may email a scanned a completed and signed copy along with a copy of the patient’s valid photo ID to email@example.com OR fax the completed and signed form and a copy of the patient’s valid photo ID to Medical Records at 415-448-1568.
Note: Requests for medical/dental records are processed in the order they are received. Medical/dental records will be delivered within 14 calendar days upon receipt of the request. If you have any questions regarding the release of health information, please call 415-798-3124.
Mail the completed form to:
Marin Community Clinics
C/O HIMS Dept.
PO Box 5008
Novato, CA 94948
Acceptable forms of original photo ID include:
- Driver’s license / Identification Card
- Immigration Documentation
Release of information charges:
In most cases, there are no fees for receiving copies of your medical records. You will be notified in advance if any fees prior to releasing your records.
A patient’s personal representative must bring their picture ID and the durable power of healthcare. If the patient is deceased, the personal representative must provide proof of being the executor or administrator of the estate and provide the patient’s death certificate.
For disclosures when your medical records contain information for one or more of the following categories the patient or authorized representative is required to indicate this by initialing the appropriate section in the Authorization for Release of Health Information form:
The following records will not be released without an additional authorization (please initial beside each item you wish to include on the form):
- Mental Health Treatment
- HIV/AIDS-Related Information
Attorneys, Insurance Companies and All Other Requesters
To obtain a copy of a medical record from Marin Community Clinics, download, and have the patient complete, sign, and date the Authorization for Release of Health Information form (English / Spanish) and mail it to the attention of the Health Management Information Systems Department according to the address provided on the form. The request must be signed and dated within the past 60 days unless the authorization includes an expiration date. Unsigned and undated requests cannot be processed. Please indicate on the authorization form if you prefer that the copy of the medical record be sent to the address specified on the authorization form or if you prefer to pick up your copy from one of our Clinics during business hours.
Other Permission for Disclosure of Health Information forms:
- To expedite the process, you may email a completed scanned and signed copy along with a copy of the patient valid photo ID to firstname.lastname@example.org OR fax the completed and signed form and a copy of the patient’s valid photo ID to Medical Records at 415-448-1568.
- Permission to share information with Family, Friends, and Caregivers (English / Spanish)