Request Your Medical Records
Gerardo Guevara, DC QME, 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.
Download, fill out and sign the form below.
Please, make sure to include the dates of service, without this information, your request for records cannot be completed.
Once you have complete the request form, mail or email it to:
- 1142 S. Diamond Bar Blvd 310, Diamond Bar, CA 91765.
Emails requesting medical records must include a completed and signed Authorization for Disclosure of Health Information form.
Patients’ Frequently Asked Questions
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 simply be email or fax to our exchange of health information service Records Source.
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. 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.