Records Release

        

PET MEDICAL CENTER ~ LET OUR FAMILY SERVE YOURS! 

         Family Owned & Operated Since 1973

 

       1534 14th Street     Santa Monica, California 90404     Telephone: (310) 393-8218

 

 

Monday - Tuesday - Wednesday  7:30 a.m. - 8:00 p.m.    Thursday - Friday  7:30 a.m. - 6:00 p.m.   Saturdays 8:00 a.m. - 3:00 p.m.

 

We close for lunch Monday through Friday from 1:30 p.m. - 2:30 p.m.    No Doctor on site until 8:30 a.m.

 

CLICK HERE for information on Mandatory Spay & Neuter Laws

REMINDER!

Beginning

October 1st, 2008,

Pet Medical Center will no longer automatically file insurance claims.

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Telephone Us At:

(310) 393-8218

 

 

BUY YOUR PET

PRESCRIPTIONS

ONLINE - JUST

CLICK BELOW

 

Click Below For

Pet Health Videos!

 

CLICK HERE

to find out about

our Pet Packages!

 

 

 

Click Above

To Visit Our

Rainbow Bridge

Pet Memorial

 

 

 

CLICK HERE

to read our

Monthly

Newsletter

 

 

Be sure to read

Dr. Michael Yuan's

comic strip

"Cat Boxes"

 

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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

 

 

 

 

Requester Notice

 

 

CA Health and Safety Code ss1795.12

“…Any patient’s representative shall be entitled to copies of all or any portion of the patient’s records which he or she has a right to inspect, upon presenting a written request to the health care provider specifying the records to be copied, together with a fee to defray the cost of copying, which shall not exceed $0.25 per page.  The health care provider shall ensure that the copies are transmitted within 15 days upon receiving the request.”

 

As a courtesy to you, there is no charge for copies of records to be sent to another veterinarian for continuing care.  For any other purpose, there is a pre-payment of $5.00 payable to Pet Medical Center.

 

If records are to be mailed, there is an additional $5.00 charge.

 

An invoice for the balance will be sent to you after the records are copied. 

 

Upon receipt of full payment, the records will be forwarded to you.

 

By clicking on the "SUBMIT" button below, you acknowledge having read and understood this notice.

 

 

Client Name        Date 

 

 

 

Pet Medical Center Only

 

 

Date Request Received            Doctor Authorization 

 

Date Copied                                 Payment Received     

 

Date Sent       

 

 

 

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