Emanate Health is committed to protecting your medical information. For information about your rights and the obligations you have regarding the use and disclosure of your medical information, please see our Notice of Privacy Practices.
Request for medical records for Queen of the Valley Hospital, Inter-community Hospital, Foothill Presbyterian Hospital
- Download and print the Authorization for Disclosure of Protected Health Information Form.
- Authorization for Disclosure of Protected Health Information (English)
- Authorization for Disclosure of Protected Health Information (Spanish)
- Fax or mail the completed signed form back to us, to the attention of the Health Information Management Office.
- Mailing Address (for all three hospitals):
Emanate Health Queen of the Valley Hospital
1115 S. Sunset Ave
West Covina, CA 91790
- Fax: 626.814.2560
Request for medical records for Glendora Surgery Center
- Records for service: 9/1/2013 through 08/31/2022
Please use Authorization for Disclosure form and follow directions above
- Records for service: 9/1/2022 and later
Please contact the Glendora Surgery Center directly
*Please be sure to complete and sign the form before sending.
Only the patient, parent/legal guardian, or the patient's legal health care representative can sign the form to release medical records. If you are requesting records on behalf of the patient or as the patient’s representative, please provide a copy of an Advance Directive/Durable Power of Attorney for Healthcare/Conservatorship.
Unsigned requests cannot be processed and failure to provide all necessary information may invalidate the request.
For assistance and additional information or questions, please contact us during business hours at:626.814.2440
Monday - Friday
8:00am – 5:00pm
Please check our Hospital Visitation Guidelines for more information about our visitation policies.