Forms

Medical

Please submit completed medical forms by fax to (323) 442-6029 or by e-mail to ecohenshc@med.usc.edu.

HIPAA Privacy Notice
Patient Consent Form
Flu Consent Form

Counseling

Please submit completed counseling forms by fax to (323) 442-6029 or by e-mail to ecohenshc@med.usc.edu.

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 ecohenshc@med.usc.edu . 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

Insurance

Please submit completed insurance forms by fax to (323) 442-6212 or by e-mail to carabant@usc.edu .

2015-2016 Summary of Benefits and Coverage
2015-2016 Aetna Plan Document
2014-2015 Aetna Plan Document
2013-2014 Summary Of Benefits
2013-2014 Aetna Plan Document