Medical Records Request Form
This form
is
used to request copies of
medical records. Only patients or their legal representatives may make a medical record
request
.
Texas Children’s may verify your identity/guardianship.
Some requests may be subject to a reasonable fee.
Part
1
:
Patient Information
N
ame:_______
_____
______________________
_________
Date of birth (MM/DD/YYYY): ______________
___
__
A
ddress:_________
_______
___________________
_____________
_______________________
_____
__
P
hone:________
___________
___________
City
:______________
____
______
_____
_____
________________________
___
__
_____
______
State
:_
___
__
__
__
__
_____
ZIP:
__
___
__
_
__
____
___
Part
2
:
What information are you
requesting
? (
Mark
all that apply)
Date(s) of service:___
_
___
____
_________
__________________________
________
Clinic/ Outpatient Record. Clinic:_____________________________________
Provider:________________________________________
Inpatient
Abstract
(
includes face sheet, discharge summary, history and physical exam, operative and pathology reports, consultation reports,
radiology reports and EEGs
)

Discharge Summary

History/Physical Exam

Operative Reports

Pathology Reports

Consultation Reports

Radiology Reports & Images

EKG/Cardiology Reports

Lab Results

Progress Notes

Past/Present Medications

Patient Allergies

Billing
(Claim)
Information

Other________________

All health information
Mental
/behavioral
health records (may require physician/psychologist approval):
Psychiatric/mental health records
Neuropsychological testing
Other
__________________________________
Part
3
:
Purpose of Disclosure
:
(
P
lease
select only one box
)

Personal Use
(Skip Part 4 below)

Treatment/Continuing Medical Care

Billing or Claims

Insurance

Legal Purposes

Disability
Determination

School

Employment

Other ________________________
Part
4
:
To be completed only
for third
-
party disclosures
.
(If the disclosure is for personal use, skip this section
.
)
I want the requested medical records to be sent
to the third
-
party (for example, an employer or a school) I have indicated below. My completion of this
form serves as authorization for Texas Children’s to disclose these records to this person or group
. I understand that once my
information leaves Texa
s
Children’s,
Texas Children’s is
no
longer
able to protect th
e
information, and the recipients of
my
information may not be legally required to protect
my
information.
Name:____________________
____________
______
_______
________________
________
__________Phone__________
________
_____________
Mailing
Address:_
______
_
_________________________
______
________________
_______________
___________
___________________________
Part
5
:
Check here if you wish to have the records provided in electronic format
(CD).
This is available only for records
within
Texas Children’s electronic health record
system.
Part
6
:
Terms of Authorization
:
I understand this authorization may be revoked in writing at any time, according to the instructions in
Texas
Children’s Notice of Privacy Practices, except to the extent that action had been taken in reliance on this authoriza
tion. Unless otherwise revoked,
this
authorization will expire
on the soon
er
of
180 days
from the date of this authorization
or on th
e date indicated here:_______________________
.
If the
person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulat
ions, the information described
above may be re
-
disclosed and no longer pro
tected by those regulations.
The information released may contain information related to AIDS or HIV
infection; drug or alcohol abuse; mental or behavioral health or psychiatric care,
except for psychotherapy notes.
Texas Children’s
will not
condition
tr
eatment or payment on my completion of this form.
Signature:
___________________
__
_______
_______________
_____
________________________
_______
__
Date:
__________
________________
Printed name:________
_______________
______
_________________
_______
_________
Relationship to patient: _____________
_______
________
A minor individual’s signature is required for the release of certain types of information, including for example, the releas
e of information related to cer
-
tain types of reproductive care, sexually t
ransmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (
See, Tex. Fam. Code
§
32.003).
Minor’
s Signature:
_________________________
____
__
_______________
________________________
_____Date:___
________________________
M
ail or deliver completed forms to
:
Release of Information, MC A
-
1195
Texas Children’s
6621 Fannin Street
Houston, TX 77030
Please Include Copy of Driver's License/ ID
May Be Faxed To (832) 825-9056/ 0110