How to Fill Out and Submit the Harbor-UCLA Medical Records Request Form

To request your medical records from Harbor-UCLA Medical Center, complete the LA County Department of Health Services form HS-1015, “Authorization for Release of Protected Health Information,” and submit it to the hospital’s Health Information Management (HIM) department. This is the Harbor-UCLA medical records request form, and once HIM receives a complete, signed copy, California law gives the hospital 15 days to send your records.¹

Where To Get the Form

The form is available two ways. You can download HS-1015 from the LA County DHS website, or pick up a blank copy at the HIM office at Harbor-UCLA, Room PCDC 101, 1000 W. Carson St., Torrance, CA 90509. The office is open Monday through Friday, 8:00 a.m. to 4:30 p.m.² The same form is accepted at any LA County DHS facility, so you can also grab one from a closer clinic if that’s easier.³

Fill it out before you go if you’re planning to drop it off in person. That saves a second trip if something is missing.

Filling Out the Form

Every field on the form matters. An incomplete authorization gets sent back, and the 15-day processing clock only starts once HIM has a valid, complete request.

Patient Information

You’ll enter the patient’s last and first name, date of birth, medical record number, last four digits of the Social Security number, phone, and full mailing address.⁴ If you don’t know your medical record number, call HIM at (424) 306-4100 and ask them to look it up before you submit. Leaving both the record number and the SSN digits blank makes your chart harder to find and slows everything down.

Release From and Send To

In the “Release Information From” box, list Harbor-UCLA Medical Center, 1000 W. Carson St., Torrance, CA 90509. In “Send Information To,” write the full name, address, phone, and fax or email of whoever should receive the records. That might be another doctor’s office, an insurance company, an attorney, or you.

Record Types and Dates of Service

Check “All records” or pick specific categories: discharge summaries, lab results, imaging reports, operative notes, and so on. Choose only what you need. Requesting everything when a single lab panel would do drives up your copy fees and lengthens processing. Enter a date range for the visits you want, or check “All Dates” for a complete history.⁴

Delivery Format

Pick how you want the records: paper, electronic, fax, or email. Electronic delivery is often cheaper. Federal rules cap the charge for an electronic copy of records already stored digitally at a flat $6.50, covering labor, supplies, and postage combined.⁵

Purpose, Expiration, and Signature

Choose a purpose from the listed options (continuing care, insurance, legal, personal use). California requires an expiration date or event, and it can’t run longer than one year unless you specifically ask for more.⁶ Then sign and date it.

If you’re signing for someone else, note your relationship: parent, legal guardian, power of attorney, conservator, or executor for a deceased patient’s estate. Attach proof of that authority when you submit the form.⁶

Extra Steps for Sensitive Records

The standard signature does not cover every category of record. HS-1015 has an “Additional Authorizations” section where you must initial next to each sensitive type you want released. Skip an initial, and that portion of your file will be redacted from what you get.

HIV Testing and Results

California requires a separate written consent for every disclosure of HIV test results.⁷ On the LA County form, initial the HIV line to release them. This applies to test results specifically, not to voluntary disclosures you made to a doctor or to an AIDS-related diagnosis that shows up elsewhere in your chart.

Substance Use Disorder Treatment

Federal rules under 42 CFR Part 2 protect substance use disorder treatment records more strictly than ordinary medical data, and consent to release SUD counseling notes cannot ride along on a general authorization.⁸ If you received SUD care at Harbor-UCLA, ask HIM whether a separate consent form is needed on top of initialing the main authorization.

Gender-Affirming Care and Reproductive Services

The LA County form has separate initial lines for gender-affirming care and for contraception or abortive services.⁴ Initial the relevant line if you want those records included. Blank lines mean those records stay out.

Submitting the Signed Form

You can get the completed form to HIM three ways:

In person at Room PCDC 101 (Mail Box 26), 1000 W. Carson St., Torrance, CA 90509, Monday through Friday, 8:00 a.m. to 4:30 p.m. The clerk checks for missing fields on the spot.
By mail to Health Information Management, Harbor-UCLA Medical Center, 1000 W. Carson St., Room PCDC 101 (Mail Box 26), Torrance, CA 90509.
By fax to (310) 782-1796. Keep the confirmation page as proof of the submission date.

If you’re picking records up in person, bring a government-issued photo ID. To confirm receipt or check status, call HIM at (424) 306-4100.²

How Long It Takes and What It Costs

California law requires the hospital to send copies within 15 days of receiving a valid request.¹ The clock starts when HIM has a complete, signed form in hand, not when you drop it in the mail. If the form comes back for corrections, the clock restarts on resubmission.

Paper copies cost no more than $0.25 per page. Records copied from microfilm run up to $0.50 per page. The hospital can also charge reasonable labor for locating and copying the file, the cost of any disc or drive you request, and postage.⁹ For an electronic copy of records already kept digitally, the total is capped at $6.50 under federal HIPAA rules.⁵ Payment is usually due before release, typically by check or money order.

When You Can Get Copies Free

If you need the records to support a claim or appeal for a public benefit program, California requires the hospital to provide them at no cost. The qualifying programs are listed by name in state law: Medi-Cal, In-Home Supportive Services, CalWORKs, Social Security Disability Insurance, SSI/SSP, federal veterans disability benefits, CalFresh, government-funded housing subsidies, and tenant-based housing assistance. Free copies also apply if the records support a U visa petition or a self-petition for lawful permanent residency under the Violence Against Women Act.¹ Submit a written request with proof that the records are for one of these purposes. The hospital gets 30 days rather than 15 under this provision.

The Faster Option for Personal Viewing

If you only want to look at your own records or print them for a new doctor, skip the paperwork. Harbor-UCLA patients can self-enroll in the LA Health Portal at mywellness-ladhs.iqhealth.com/self-enroll and pull up lab results, imaging reports, immunization records, prescriptions, and doctor’s notes online or through the mobile app.¹⁰ For login help, call 866-889-9258 (available 24/7) or email LAHealthHelp@dhs.lacounty.gov.

The portal does not send records to a third party. If you need copies going to another provider, an insurer, or an attorney, you still have to file HS-1015.

Canceling a Request You Already Signed

You can revoke an authorization at any time, but the revocation only stops future disclosures. Anything already released before HIM receives your written revocation is gone. Submit the revocation in writing to the same HIM department, by mail or in person at Room PCDC 101, and keep a copy for yourself.⁴

1
California Legislative Information. California Code Health and Safety Code 123110
2
Los Angeles County Department of Health Services. Contact Us
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Harbor-UCLA Medical Center. HIPAA Related Forms
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Los Angeles County Department of Health Services. Authorization for Release of Protected Health Information
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HHS.gov. Is $6.50 the Maximum Amount That Can Be Charged
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California Legislative Information. California Code CIV 56.11
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California Legislative Information. California Code Health and Safety Code HSC 120980
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eCFR. 42 CFR Part 2 – Confidentiality of Substance Use Disorder Patient Records
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California Legislative Information. California Code Health and Safety Code 123110
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Health Services Los Angeles County. LA Health Portal