Request for Release of Health Information

UCR Student Health Services

For any inquiries regarding release of health information from UCR Student Health Services, please contact UCR Student Health Services on UCR Campus at (951) 827-3031.

For more information visit our UCR Student Health Services.

PLEASE NOTE: UCR Health is NOT UCR Student Health Services

Authorization for Release of Health Information

I am a current or past patient of UCR Health, provider or hospital

1. Download, complete and sign the UCR Health Authorization for Release of Health Information form.*
2. Send in the completed form, We want to make it easy to submit your completed form. There are 4 ways to get us your completed form. **  

Email	[email protected].edu
Fax	(951) 344-5362
Mail	UCR Health ATTN: Medical Records – Mail Code 423 900 University Avenue Riverside, CA 92521
Drop Off	UCR Health – Multispecialty Clinic UCR Health – Psychiatry Clinic UCR Health – Neurosurgery UCR Health – Women’s Health UCR Health – Pediatric Clinic

* If you are not able to download and print the appropriate form, stop by any UCR Health location to pick up the correct form
** Please allow 2 weeks for processing authorized requests

Authorization to Obtain Health Information

I am a new, referred, or transferred patient to UCR Health

1. Download, complete and sign the Authorization from Outside Facility to UCR Health form.*
2. Send in the completed form. We want to make it easy to submit your completed form. There are 4 ways to get us your completed form. **  

Email	[email protected]
Fax	(951) 344-5362
Mail	UCR Health ATTN: Medical Records – Mail Code 423 900 University Avenue Riverside, CA 92521
Drop Off	UCR Health – Multispecialty Clinic UCR Health – Psychiatry Clinic UCR Health – Neurosurgery UCR Health – Women’s Health UCR Health – Pediatric Clinic

* If you are not able to download and print the appropriate form, stop by any UCR Health location to pick up the correct form
** Please allow 2 weeks for processing authorized requests

I am an Attorney, Copy Service, or Insurance Company

If you are requesting medical and/or billing records from one of more of our clinic locations, and/or one or more providers, please direct your request as follows:

Clinic Location:

Citrus Tower – Multispecialty 3390 University Ave, Ste 100 Riverside, CA 92501	La Quinta – Pediatrics 79430 Highway111, Ste 102 La Quinta, CA 92253	Airport Towers – Psychiatry 18881 Von Karman Ave, Ste 1227 Irvine, CA 92612
Citrus Towers – Psychiatry 3390 University Ave, Ste 115 Riverside, CA 92501	Silver Oaks – Women’s Health 19330 Jesse Ln, Ste 100 Riverside, CA 92501	Riverbrock – NeuroSurgery 4510 Brockton Ave, Ste 365 Riverside, CA 92501

All Attorney, Copy Service, Insurance Request must be mailed along with prepayment

Mail your request to     900 University Avenue, Mail Code 423, Riverside, CA 92521

Address Request to      UCR Health

Check Payable to         Regents UC     Tax ID# 36-4733438

Amount for:                  Medical Records – $15

                                      Billing – $15

**We do not process Imaging request, as our patients are referred outside, please request from imaging center.

PLEASE NOTE WHEN USING FEDEX – Mail to:

            Citrus Towers UCR Health

            3390 University Ave, Ste 100

            Riverside, CA 92501

NOTE – our office no longer invoices. Our office requires payment with request. we will “Return to Sender” due to request missing payment, incorrect payee and/or incorrect amount. Please take the initiative to read and keep for future requests.

Other

Questions	For questions regarding submitted requests, please call 1.951.394.9034
MyChart Patient Portal	You may also access and review your test results, upcoming appointments and communications with your provider by accessing MyChart Patient Portal.
Compliance Office	Additional access to your records can be scheduled through the Compliance Office by calling 951.827.4672.

Health Information Management Office