If you or your minor child has or is receiving services from EMQ FamiliesFirst you may request a copy of the medical record. To request a copy of a minor child’s record you must be the legal guardian.

Your request will be evaluated based on the applicable California Laws and Federal Regulations in conjunction with HIPAA in regard to the release of health information.  

» Request for Access to Medical Records
Use this form if you want to request a copy of or to view the medical records.

To request that we send to another health care provider health information that EMQ FamiliesFirst retains on you or your minor child, complete the release of information form below.

» Request for Release of Medical Records
Use this form if you want to request the release of medical records.

You can mail or fax your completed request form to the address or fax number below. If you have questions, please contact Privacy Officer Geoff Premeau at (408) 364-4024 or gpremeau@emqff.org.

Send by mail to:
EMQ FamiliesFirst
Health Information Management
251 Llewellyn Ave.
Campbell, CA 95008

or send by FAX: (408) 364-7065

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