Medical Records Request Form
used to request copies of
medical records. Only patients or their legal representatives may make a medical record
Texas Children’s may verify your identity/guardianship.
Some requests may be subject to a reasonable fee.
Date of birth (MM/DD/YYYY): ______________
__________________________
Clinic/ Outpatient Record. Clinic:_____________________________________
Provider:________________________________________
includes face sheet, discharge summary, history and physical exam, operative and pathology reports, consultation reports,
radiology reports and EEGs
Radiology Reports & Images
health records (may require physician/psychologist approval):
Psychiatric/mental health records
Neuropsychological testing
__________________________________
Treatment/Continuing Medical Care
Other ________________________
(If the disclosure is for personal use, skip this section
I want the requested medical records to be sent
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, and the recipients of
information may not be legally required to protect
Name:____________________
__________Phone__________
_________________________
___________________________
Check here if you wish to have the records provided in electronic format
This is available only for records
Texas Children’s electronic health record
I understand this authorization may be revoked in writing at any time, according to the instructions in
Children’s Notice of Privacy Practices, except to the extent that action had been taken in reliance on this authoriza
tion. Unless otherwise revoked,
authorization will expire
from the date of this authorization
e date indicated here:_______________________
person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulat
ions, the information described
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.
eatment or payment on my completion of this form.
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 (
_________________________
ail or deliver completed forms to
Release of Information, MC A
Please Include Copy of Driver's License/ ID
May Be Faxed To (832) 825-9056/ 0110