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FYI10-20, Obtaining medical records from Kaiser Permanente - los angeles county clerk records online



|FYI FYI FYI FYI |

|F O R Y O U R I N F O R M A T I O N |
| |
| |Issue |10-20(REV) |Date: |01/24/14 | |
| | | | |/10 | |
| |
| |
|OBTAINING MEDICAL RECORDS FROM KAISER PERMANENTE |
| |
|The contact list on page 3 has been updated |
| |
|This is to inform staff that DCFS and Kaiser Permanente (Kaiser) have jointly developed the new: “DCFS/Kaiser Permanente Medical Records Request FAX” (Kaiser FAX), a |
|two-way FAX form designed to expedite the process of obtaining medical records for DCFS involved children/youth (please refer to the attached form). The form will |
|also be available on the Forms Page of LA Kids. When completing the Kaiser FAX form the following information is of particular importance and must be included to |
|ensure your request is not delayed: |
| |
|The name and phone number of the child/youth’s Kaiser doctor. |
|The date and time records are needed by. |
|Legal authorization for Kaiser to release information to DCFS (use the check boxes above Section I) |
|Either the DCFS CPH Referral Number (19 digits) or Case Number (7 digits) and the Kaiser Permanente Medical Record Number (if available). |
|Completion of Section II: Information Requested. |
|Dates of treatment or range; facility/facilities where treatment took place and; a clear statement of what information is being requested. |
| |
|NOTE: Consult with the PHN for assistance in determining what medical information to request. |
| |
|The completed Kaiser FAX form must be faxed to the appropriate Kaiser Medical Records Contact (KMRC) listed on page two of the Kaiser FAX form or it will not be |
|processed. To arrange an “in person” pick up, the CSW must contact the KMRC after the Kaiser FAX has been sent. |
| |
|The KMRC will make every effort to obtain the requested records by the date the CSW needs them and either FAX them to the CSW (using the two-way feature of the Kaiser |
|FAX form) or have the records ready for the CSW to pick up in person by the date requested. The KMRC will communicate with the CSW regarding any additional |
|information Kaiser needs to be able to comply with the request and the KMRC will notify the CSW if there will be delays in completing the request timely. |
| |
|For further assistance or to discuss difficulties in obtaining medical records from Kaiser, please contact: The DCFS Child Welfare Health Services Section at: |
|213-351-5714. |
| |[pic] | If you have any questions regarding this release please |
| | |e-mail your question to: |
| | | |
| | |Policy@dcfs.lacounty.gov  | |


Clerical Handbook: http://lacdcfs.org/Policy/Hndbook%20Clerical/Default.htm
Eligibility Handbook: http://lacdcfs.org/Policy/Hndbook%20FCE/TableofContents.htm
Child Welfare Services Handbook: http://lacdcfs.org/Policy/Hndbook%20CWS/default.htm
FYI’s: http://lacdcfs.org/Policy/FYI/TOCFYI.htm
[pic] [pic][pic]
DCFS Medical Records Request Los Angeles County Department of Children and Family Services
Patricia Ploehn, LCSW, Director

Fax to Kaiser Permanente from DCFS ( URGENT!

|To be completed by DCFS: |
|To: |      |From: |     , CSW |
|Fax: |      |Fax: |      |
|Phone: |      |Phone: |      |
|Doctor: |      |SCSW: |      |
|Phone: |    |Date: | |


A Kaiser Medical Records Contact list containing FAX numbers is on page 2 of this form.

The patient named below has been placed in the care and custody DCFS.
DCFS is requesting medical information as part of an ongoing child abuse investigation (see Referral/Case Number below).
Parental Consent is attached.
A Court order is attached.

Section I: PATIENT INFORMATION (to be completed by DCFS)
|Patient Name (last, first, middle initial): |
|      |
|Birthdate: |DCFS CPH Referral Number (19 digits) or Case Number (7 digits): |Kaiser Medical Record Number (if known): |
|      |      |      |
|Address |
|      |
|City: |State: |Zip: |Phone: |
|      |      |      |      |

Section II: INFORMATION REQUESTED (Check all that apply) (To be completed by DCFS)
| Clinic visit notes | Complete Medical Record |
|Emergency Room Report |CalEMA 2-900 and/or CalEMA 2-925 Reports |
|Surgical (operative report, path report) |Therapy Notes (Specify: PT, Speech, Radiation, Chemo, etc.) |
|Hospitalization (H& P, Consult, Tests, Surgical, Discharge Summary) |Records related to a specific injury with the following date (e.g. workers’ |
|X-ray Films, Diagnostic Scans on CD’s (MRI, PET, CT, ultrasound, bone scan) |compensation injury): ________________________ |
|Test results (Specify: Lab, X-ray, EKG, etc.) |Other : ________________________________________ |
|For the following dates of treatment: (for example: specific date 1/25/08 or; range of dates Jan-July 2008 or; all dates of service). |
|      |
|From the following facility/facilities:       |
|Please provide the following information (Be SPECIFIC):       |


Fax to DCFS from Kaiser Permanente

|To be completed by Kaiser Permanente: |
|To: |     , CSW |From: |      |
|Fax: |      |Fax: |      |
|Phone: |      |Phone: |      |
|SCSW: |      |Doctor: |      |
|Date: | |Phone: |    |

Please refer to DCFS Procedural Guide 0600-500.20, Protected Health and Medical Information: Access and Sharing:
http://www.lacdcfs.org/policy/hndbook%20cws/0600/060050020PMIv1009.doc

NOTICE TO RECIPIENT: If you are not the intended recipient of this FAX, you are prohibited from sharing, copying, or otherwise using or disclosing its contents. If you have received this FAX in error, please notify the sender immediately by telephone and destroy this FAX and any attachments without reading or sharing them. Thank you.

Antelope Valley
Antelope Valley
Release of Information Unit
Insurance Department
43112 North 15th Street West
Lancaster, CA 93534
Phone: 661-726-2266
Fax: 661-726-2430
Jaben D Bilker/CA/KAIPERM, Manager
661-726-2216 Tie line 351

Baldwin Park
Release of Information Unit
Health Information Management Department
1011 Baldwin Park Blvd.
Baldwin Park, CA 91706
Sheila Belzonie 626-851-5267
Fax 626-851-7077


Downey Medical Center
Release of Information Unit
Medical Correspondence
9400 E. Rosecrans Ave
Bellflower, CA 90706
Phone: 562-461-4111
Fax: 562-461-4490
Melissa Romero, Manager
562-461-4488 Tie line 325


Fontana Medical Center
Release of Information Unit
Patient Support Services
17284 Slover Avenue, Suite 202
Fontana, CA 92336
Lynette Palmer 909-609-3210


Kern County
Release of Information Unit
Medical Correspondence
PO Box 12099
Bakersfield, CA 93389-1299
Phone: 661-852-3450
Fax: 661-852-3446
Connielyn A DeVera/CA/KAIPERM, Assistant Department Administrator
661-852-3451 Tie line 378

Los Angeles Medical Center
Release of Information Unit
Medical Correspondence
3699 Wilshire Blvd. 3rd Floor
Los Angeles, CA 90027-0990
Phone: (323) 783-2400
Fax: (323) 783-5086
Evans C Porcil/CA/KAIPERM, Manager
(323) 783-2416 Tie line 363

Orange County
Medical Correspondence
1011 S. East Street
Anaheim, CA 92805
Phone: 714-284-6634
Fax: 714-284-6872
Reynaud D Rosales/CA/KAIPERM, Supervisor
714-284-6815 Tie line227



Panorama City Medical Center
Release of Information Unit
Health Information Management Department
13652 Cantara St.
Panorama City, CA 91402
Chau Tran 818-375-3147
Fax 818-375-4313


Riverside Medical Center
Release of Information Unit
Insurance Department
10800 Magnolia Avenue
Riverside, California 92505
Phone: (951) 353-4470
Fax: (951) 353-4077
Joan E Yapp/CA/KAIPERM
Office:  (951) 271-5102 Tie Line 268

San Diego Medical Center
Release of Information Unit
7385 Mission Gorge Road
San Diego, CA. 92120
Phone: 619-583-4293
Fax: 619-229-7511
Julie D Wilson/CA/KAIPERM, Supervisor
(619) 528-6751 Tie line 280

South Bay Medical Center
Release of Information Unit
Health Information Management Department
25825 S. Vermont Avenue
Harbor City, CA 90710
Phone: (310) 517-2905
Fax: (310) 517-2179
Phyllis X Hunt/CA/KAIPERM, HIM Director
310-517-2498 Tie line 340

West Los Angeles Medical Center
Release of Information Unit
Medical Correspondence
6041 Cadillac Avenue
West Los Angeles, California 90034
323-857-2751
323-857-2598
Colleen R Roman/CA/KAIPERM
(323) 857-2755 Tie line 390

Woodland Hills Medical Center
Release of Information Unit
Insurance Department
5601 De Soto Avenue
Woodland Hills, CA 91367
Phone: 818 719-2670
Fax: 818 719-2619
Becky A Weiner/CA/KAIPERM, Department Administrator
818 719-2025 Tie line 348
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Please have documents
available by:
Time:
Date:

( CSW will pick-up


Where is the Los Angeles County Recorder? Trfc Collision-Unkn Inj. I605 S / Alondra Blvd Ofr. OFR. Santa Fe Springs. Details. 03226. 8:15 PM. Assist with Construction. I110 S / W MANCHESTER AVE W ONR.