Requests for medical records must be made in writing. Please follow these steps.
1. Print out and complete an Authorization to Release Protected Health Information
Authorization to Release Medical Information (English)
Authorization to Release Medical Information (Spanish)
2. Mail your completed form to:
Shiley Eye Institute
Attn: Medical Records
9415 Campus Point Drive, MC 0946
La Jolla, Ca 92093-0946
Fax it to Medical Records at 858-822-1849
A valid authorization MUST contain the following information or the request will be returned:
• Patient’s full name and date of birth (list any other names the patient may have had)
• Medical record number (if available)
• Specific information being requested (i.e., type of report/information and dates of service, etc.)
• Purpose for which the information may be disclosed (i.e., personal use, continuity of care, legal matter)
• To whom the information is to be sent (name and address)
• Specify authorization’s expiration date if desired (otherwise, the authorization will be valid one year from date signed)
• The patient’s signature or a patient’s legal representative’s signature. Authorizations signed by a representative must be verified. Please include a copy of one of the following documents indicating either:
•• Legal guardianship papers, or
•• Advance Directive/Healthcare Power of Attorney (Download in English | Spanish), for patients unable to make healthcare decisions, or
•• Designation of Personal Representative Form (Download in English | Spanish) which allows the representative to act on the patient's behalf with regard to personal health information.
• Please note that unsigned requests will not be processed
• Date of the signature
You may contact the Shiley Medical Records office by phone at 858-534-2219.
It is in your best interest to know and understand your plan benefits, as well as any deductible and co-payment amounts that you are responsible for paying. If you do not understand your coverage, we recommend you contact your insurance carrier. They should be able to explain if the service is covered or not. You can also contact a UC San Diego Health System financial counselor to review your benefits with you.
UC San Diego will make every attempt to ensure that the service(s) we provide has been authorized by your insurance prior to the service(s) being rendered. Not all insurance companies will provide a pre-authorization; therefore, it is UC San Diego Health System's expectation that you are familiar with your insurance benefits. If you are unsure of your medical benefits, call your insurance company to find out if the service(s) you need are a covered benefit. If authorization for service(s) is/are denied by your insurance carrier, we will inform you that authorization for medical service(s) were denied. You are financially responsible and will be billed for services not covered by your insurance.
All charges for doctor visits and any other services you receive are sent to your insurance carrier as a claim. Unfortunately, we do not know in advance whether those services will be covered by your insurance. Claims that we submit to your insurance carrier are paid based upon your individual benefits. Your insurance carrier will not determine if a service is covered until they receive and process the claim.
Most health insurance claims are processed without problems. However, insurance carriers are becoming more watchful of costs. This sometimes results in services that were previously covered no longer being covered. Any non-covered services must be paid for by you. We recommend you call your insurance company, read your health care benefits coverage information carefully, and do your research so you understand what is covered under your plan.
If you have questions regarding your billing statements, call our customer service department at 619-543-3000, Monday through Friday between the hours of 8:00 a.m. to 4:30 p.m.
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