Please submit completed medical forms by fax to (323) 442-6029 or by e-mail to

HIPAA Privacy Notice
Patient Consent Form
Flu Consent Form


Please submit completed counseling forms by fax to (323) 442-6029 or by e-mail to

Counseling Packet

Health Information Management

(Medical and Behavioral Health Records)
Per ECSHC policy, “Medical records retention is based on the type of medical record. Hard copy medical records are retained for ten years from last visit date. Records older than ten years from last visit date are identified for destruction and are performed by the secure, offsite record storage facility.”

To view our entire policy on Medical Record Retention, please click here.

To request copies of your health information records, please complete a “Medical Records Release Form” OR a “Release of Behavioral Health Information” form. Once you have completed the form, please fax to (323) 442-6029 or e-mail to . It is important for you to include your contact information for us to be able to contact you regarding your request. Once you have sent the complete form, please call (323) 442-5631 during clinic hours to check whether we received it. Due to the volume of requests we receive, the estimated timeline that requests are completed is usually between 7-15 working days.


ECSHC Medical Record Release Form
Behavioral Health Release of Information


Wellness Event Sponsorship Request Form