Request for Medical Records To Us

Prime Wellness Community Health Center - Los Angeles/Westchester
8610 S Sepulveda Blvd Suite 104, Los Angeles, CA, 90045

Prime Wellness Community Health Center - Inglewood
133 N Prairie Ave Suite B, Inglewood, CA 90301

Name/Clinic (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Patient Name (Last, First) (required)

Date of Birth (required)

Name of Parent or Legal Guardian (if minor)

Address

City

State (required)

Zip Code

Home Phone Optional - Format: 123-456-7890 or (123) 456-7890

Please enter a valid US phone number.

Work Phone Optional - Format: 123-456-7890 or (123) 456-7890

Please enter a valid US phone number.

Please specify records to be released (required)

Signature (required)

Date (required)

Note: This authorization will expire one year from the date signed.