A patient, or his/her legal representative, may obtain a copy of their medical records, or have copies of the medical records sent to another health care provider. John C. Fremont Healthcare District requires a completed and signed Authorization for Use or Disclosure of Health Information form before releasing any documents to anyone, including the patient, in certain cases a patient's physician, psychologist or social worker may also be required to approve a request made using a release form.
How to Request a Copy of Your Medical Record
- Print and complete the Authorization for Use or Disclosure of Health Information form:
- The release form must be completed, dated and signed
- We ask that you specify what components of your medical records you wish to obtain/release. Often, the discharge summary, operative report and history and physical contain relevant information to suit your needs.
- Requests must be specifically signed if requesting/authorizing the following information:
- Psychiatric Care
- Alcohol/Drug abuse
If you have any questions regarding release of health information, please call 209-966-3631 Ext 5015.
Hours of operation for the Health Information Management (HIM) Department: 8:30 AM to 5:00 PM Monday through Friday. We are closed on most national holidays.
You can fax or mail all completed and signed authorizations to:
John C. Fremont Healthcare District
Health Information Management - ROI
P.O. Box 216
Mariposa, CA 95338
You can also hand carry to the front lobby of the John C. Fremont Hospital: 5189 Hospital Road, Mariposa, CA 95338
The release of information staff will contact you regarding receipt of your request, expected turnaround time and payment due. Please allow up to fourteen calendar days for your request to be processed. If you indicate the option to pick-up on your release form, you will be contacted by the ROI office when your records are ready. A photo ID is required. 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 along with a photo ID.
Release of Information Records
The first 20 pages we provide for your personal use is at no cost. For requests in excess of 20 pages the cost will be assessed based on California state law and the ROI staff will provide a breakdown prior to the release of the records. All costs for medical records must be paid in full prior to receiving the records.
If you have questions regarding your billing statement, please contact the John C. Fremont Healthcare District's Finance Department at 209-966-3631 Ext. 5120.
Imaging Department Records
If you are requesting radiology images please contact the John C. Fremont Healthcare District's Imaging Department at 209-966-3631 Ext 5041.