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Patient Forms
Download forms and fill them out in advance of your visit to minimize wait time.
To Request a Copy of Your Medical Records
To request your medical record, you can complete this form:
The form must be completed, dated and signed. We ask that you specify what components of your medical records you wish to obtain.
You can send us a written request with your first name, last name, date of birth, type of documents you are requesting and your signature to authorize release of this information.
Send your request to the following address:
Cardio- Pulmonary Associates Medical Group, Inc.
30 Garden Court
Monterey, CA 93940
You also may submit your request in person at our office.
If you have any questions regarding release of health information,
please call (831) 646-8570.
FEES
Your request will be processed within 15 days. If you indicated the option to pick up, you will be contacted by our medical records department when your records are ready. You can pick up your records at our office from 8:30 a.m. to 5:30 p.m., Monday to Friday.
We charge .25 cents per page to copy medical records and an administrative fee of $10.00. Cardiovascular testing CD's will be processed for $10.00. We will notify you by phone in advance of the total charge to retrieve your records. Mailed records will be charged an estimated postage costs.
There will be no charge if request is going to another health care facility to maintain continuity of care.
To ensure your request is handled promptly and accurately payment must be made at the time of your request.
ADDITIONAL INFORMATION
If an individual other than the patient is picking up the records, then that individual must have an original signed authorization letter from the patient and along with a photo ID.
Privacy Practices
Cardio-Pulmonary Associates Medical Group, Inc. is committed to protecting your medical information. For information about your rights and the obligations we have regarding the use and disclosure of your medical information, please see our Notice of Privacy Practices
The form on this page is in Portable Document Format (PDF). This document can be viewed using Adobe Acrobat Reader. If you do not have Adobe Acrobat Reader, you can download it for free from Adobe's Web site.
