Third Party Requestors
Your information will be verified, please provide your FIRST NAME, LAST NAME and your firm's shared/dedicated EMAIL ADDRESS, to expedite your registration process. Without this information, your registration might not be processed.
Patients Records Request
Gerardo Guevara, DC QME requires a completed and signed Authorization for Disclosure of Health Information form before releasing any documents to anyone, including the patient. Please download, fill out and sign any of the forms provided below.
Once you have completed the forms, mail or email them to:
- 1142 S. Diamond Bar Blvd #310, Diamond Bar, CA 91765.
Emails requesting medical records must include a complete and signed Authorization for Disclosure of Health Information form.
All requests are subject to a thirty business days turnaround, however, some requests may be completed sooner depending on the file situation. PLEASE do not call us during this period of time. We'll keep you posted on any further updates.