Custodian of Records

Custodian of Records

Phone: (714) 834-3536
Fax: (714) 835-9312
Mail: HCA / Custodian of Records
P.O. Box 355
Santa Ana, CA 92702

Find format and accessibility information when you read about downloading files.

Requesting Medical Records — Protected Health Information (PHI)

Any time a patient is treated by the Health Care Agency, a medical record is made. Your medical record is protected under State and Federal confidentiality laws including HIPAA. The Custodian of Records office oversees all requests for medical records maintained by the Health Care Agency. For more information please visit the County of Orange HIPAA web site.

When you receive immunizations at a Health Care Agency clinic, you are given a copy of your "shot card" to keep. If you need to request an additional copy of your immunization information, you can return to the Immunization Clinic and request an additional copy and complete an authorization form at the clinic or complete the "Authorization to Use and Disclose Protected Health Information form on this page.

The Custodian of Records office oversees all requests for medical records maintained by the Health Care Agency. A copy of your medical record can be released to you or someone you identify in a signed patient authorization (a third party). Use the “Authorization to Use and Disclose Protected Health Information” form below to request a copy of your medical record, COMPLETE all required information and SIGN.

Phone: (714) 834-3536
Fax: (714) 835-9312
Mail: HCA / Custodian of Records
P.O. Box 355
Santa Ana, CA 92702
Hand Deliver: Office of Custodian of Records
200 W. Santa Ana Blvd., Suite #125
(entrance on Sycamore)
Santa Ana, CA 92701

The following authorization form meets HIPAA regulations and can be used to request records. The usual turnaround time is 7-10 days to process the request for copies of medical records. Some fees may apply.

Medical Records Forms

Description

English

Farsi

Spanish

Vietnamese

Authorization to Use and Disclose Protected Health Information (PHI) - This authorization form is used by County of Orange clients to request a copy of their medical information or to request that their medical information be released to another health care provider. PHI Form in PDF PHI Form in Word

PHI Form in PDF PHI Form in Word

PHI Form in PDF PHI Form in Word

PHI Form in PDF PHI Form in Word

Revocation of Authorization to Use or Disclose Protected Health Information - This form is now required under HIPAA. If the client/patient wants to revoke an authorization, it must be done in writing and will be processed through Custodian of Records office. Instructions available in Word or PDF format. Revocation of Authorization Form in PDF 
Request for Special Restriction on the Use or Disclosure of PHI - This form is used by a County of Orange client to request restrictions on the release of their medical information
Termination of Special Restriction - This form is to be completed by client or by HCA Program to communicate and document cancellation of restrictions on medical
Request for Restriction on the Manner/Method of Confidential Communications – This form is used by a County of Orange client to request special arrangements for communication of their medical information, such as using a cell phone or work phone instead of a home phone.
Request to Amend PHI - This form is used by a County of Orange client to request an amendment to their medical information. .
Request for an Accounting of Disclosures - This form is used by a County of Orange client to request an accounting of medical disclosures that the client might not otherwise be aware of, such as reporting a communicable disease.

Access To Public Records

Frequently the Health Care Agency receives requests from the public and members of the media to access public records. The California Public Records Act requires public agencies to provide access to its records. These requests may ask for information maintained by the Agency in regards to inspections and investigations pertaining to Agency evaluations or regulations, for statistical data, for policies, for reports, etc. Certain information, such as names of complainants, personal medical information, trade secrets persons or firms engaged in ongoing litigation, will not be released to the public as directed by the California Public Records Act and the California Confidentiality of Medical Information Act.

All requests for public records are handled through the Custodian of Record office. Please specify the name and address of the facility when completing the form.


Records Request
Title Description View
Public Records Request
  • Statistics
  • Studies
  • Policies and Procedures
Environmental Health
  • Health Inspections
  • Plumbing problem complaint
  • Food poisoning complaint
  • Water Quality
  • Medical Waste
Hazardous Waste/Underground Tanks
  • Hazardous Waste Generators
  • Underground Storage Tanks
  • Solid Waste
  • Proposition 65 Reports
  • Certified Unified Program Agency (CUPA)