Need to get a copy of your medical records? You can request that here. There are a few convenient ways to request your medical records by mail or fax.

Print a copy of our Medical Records Request Authorization Form. Please fill out the form completely, and mail the completed Authorization Request Form to:


Or fax the completed authorization form to (805) 230-2622, (818) 718-1920. For additional information, call our Medical Records Department at (805) 230-2626, (818) 718-1600.

Pertinent information from your medical record is sent free of charge when requested for follow-up care. Copies of records or pertinent information requested for other reasons are subject to processing and per-page fee.

To download a copy of the Medical Records Release Authorization Form, click here. You will need Adobe Acrobat Reader to view and print this form. Adobe Acrobat Reader is a free plug-in for web browsers. It is available for most major computer platforms.

Leo Polosajian, M.D. understands that your health information is personal. We are committed to protecting your medical information. Our policy is to provide access only to people with the need to know your medical and billing information to perform thier job.