If a minor child is receiving services from EMQ, the childâs legal representative can request a copy of the medical record. If you have received services and would like copies of your medical records, you can request a copy of your record.

Your request will be evaluated based on the applicable California Laws and Federal Regulations in conjunction with HIPAA in regard to the release of health information. Due to the nature of services EMQ provides, a summary from the clinician may be provided.

To request records, please open the necessary form below, print and complete the form. Or, call EMQ Medical Records at (408) 364-4121 to request a form.

Note that you need Adobe Reader software to view these forms. Adobe Reader software can be downloaded for free from http://www.adobe.com.

» Request for Release of Medical Records
Use this form if you want a copy of your childâs medical records sent to another health care provider.

» Request for Access to Medical Record
Use this form if you want to request a copy of or to view the medical records.

Send by mail to:
EMQ Health Information Management
251 Llewellyn Ave.
Campbell, CA 95008
or FAX: 408-364-7065