�鶹TV

Medical Records Requests

�鶹TV is not able to release your medical records to you or your designated representative without your written authorization, except as required or permitted by law. At this time, this form does not accept electronic signatures so it will need to be printed and completed, including signature and date.

To request a copy of your �鶹TV medical record:

Download the Client Request for Information.
Sign and date the Client Request.
Take a photo or scan both sides of the completed Client Request.
Fax or email along with a photo of your California ID or DL (see fax #/email below).
Alternatively, send the completed form by mail to address below.

We will then be able to process your request.

NOTE: This request may take up to 15 calendar days to complete. If there is a delay beyond the 15 days, the QI department will contact you.

If you have any questions regarding the release of your medical records from �鶹TV, you may contact our Quality Improvement Department at 408-642-6073.

Completed forms can be mailed to:

�鶹TV
Medical Records
1922 The Alameda, Suite 214
San Jose CA 95126

You can also fax the completed request to 408.642.6076 or email the form to MGraff@momentumforhealth.org

Internal Complaint/Grievance Form

Your feedback is important to us, and we are committed to providing the best possible care and
service to all our clients. If you have experienced dissatisfaction or have concerns regarding the
quality of care or services you have received at �鶹TV, we would like the opportunity to address and resolve them. Your input is invaluable in enhancing our services and ensuring that we are effectively meeting the needs of the community we serve.

You are not required to use this form to file a grievance or complaint. If you prefer, you may submit
your concerns using the following methods:

• In Person: �鶹TV, 1922 The Alameda, San Jose, CA 95126
(Alternatively, you may deliver it to any �鶹TV location)
• By Phone: (408) 261-7777
• By Mail: Attention: Quality Improvement Department, 1922 The Alameda San Jose, CA
95126
• By E-mail: feedback@momentumforhealth.org

Client information:

Please enable JavaScript in your browser to complete this form.

Name

First

Last

Client identification number (if known):

Date of birth (mm/dd/yyyy):

Phone number:

Best time to call:

Mailing address:

Name of program where client receives services:

Name of person completing form and relationship (If different from client:)

Please provide a detailed description of the complaint and/or grievance, including relevant dates and times, individuals involved, and any supporting documentation.

I hereby attest that the information provided in this grievance form is true and accurate to the best of my knowledge. By submitting this form, I acknowledge that I am filing a formal grievance and authorize the appropriate parties to investigate and address the concerns outlined herein.

Confirm

Date

�鶹TV

For Clients

Medical Records Requests

Internal Complaint/Grievance Form

Example of Modal