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Request by Patient for Access to Protected Health Information

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The patient has a right to access the Protected Health Information (“PHI”) maintained in his or her designated record set under both state and federal law.

To request a copy, fill out the form below and return to:

UCLA HIMS, Attn: Release of Information
10833 Le Conte Ave, CHS BH225
Los Angeles, CA 90095-78305

Request by Patient for Access to PHI (English)