Medical Records Request Form printable pdf download

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. Please print.

Part 1: Patient Information

Name:___________________________________________ Date of birth (MM/DD/YYYY): ___________________

Address:______________________________________________________________________________ Phone:______________________________

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 

Radiology Reports & Images

Patient Allergies

EKG/Cardiology Reports

Billing (Claim) Information

History/Physical Exam 

Other________________

Operative Reports

Lab Results

All health information

Pathology Reports

Progress Notes

Consultation Reports

Past/Present Medications

Mental/behavioral health records (may require physician/psychologist approval):

Psychiatric/mental health records

Neuropsychological testing

Other __________________________________

Part 3: Purpose of Disclosure: (Please select only one box)

Personal Use (Skip Part 4 below)

Insurance

School

Treatment/Continuing Medical Care

Legal Purposes

Employment

Other ________________________

Billing or Claims

Disability Determination

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 Texas

Children’s, Texas Children’s is no longer able to protect the 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 authorization. Unless otherwise revoked, this

authorization will expire on the sooner of 180 days from the date of this authorization or on the date indicated here:_______________________ . If the

person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described

above may be re-disclosed and no longer protected 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

treatment 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 release of information related to cer-

tain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, Tex. Fam. Code

§32.003).

Minor’s Signature:___________________________________________________________________________Date:___________________________

Mail or deliver completed forms to:

Release of Information, MC A-1195

Texas Children’s

6621 Fannin Street

Houston, TX 77030