UCLA Health
Health Information Management Services
10833 Le Conte Avenue, CHS, BH-239
Los Angeles, CA 90095
Release of Information Customer Service Office
100 Medical Plaza
Suite #140
Los Angeles, CA 90095
Monday-Friday, 8:00 am to 4:30 pm
*Walk in service available.
1260 15th Street
Suite #802B
Santa Monica, CA 90404
Monday-Friday, 8:00 am to 4:30 pm
*Walk in service available.
Telephone Number: (310) 825-6021
Business Hours: Monday – Friday, 8:00 am - 4:30 pm
Please fax authorizations to: (310) 983-1468
If you are a physician or hospital and your request is emergent please fax your request to (310) 206-4831.
1. Download and print the Authorization for Release of Health Information form below.
Authorization for Release of Information to a third-Party (a Non-UCLA Provider, Insurance Company, Attorney, etc.)
2. Complete and sign the form.
3. Fax or mail the completed form to the address or fax number above. You may also complete the authorization form in person at our office during business hours.
Please note: Unsigned and/or incomplete requests cannot be processed.
UCLA will provide the first 15 pages at no charge. There is a 25¢ per page copying fee for additional pages, plus postage. We will send you an invoice by mail to let you know the total charge for providing copies of your medical record.
Visit our frequently asked questions page for more information »
1. Download and print the Request to Amend Protected Health Information form below.
2. Complete and sign the form
3. Fax or mail the completed form to the address or fax number above. You may also complete the authorization form in person at our office during business hours.
Please note: Unsigned and/or incomplete requests cannot be processed.
