Health Insurance

Aetna Medical Claim Form
Aetna Prescription Drug Claim Form
Delta Dental Claim Form

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 Release Form
Behavioral Health Release of Information
Notice of Disclosure of Medical Information
Requesting Medical Records from Other Providers


Wellness Event Sponsorship Request Form

Wellness Event Evaluation Form