Medical records request form texas

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…Texas Medical Records Release Form will help you creat your own perfect templates, which can be used for small, medium and large-sized enterprises. All requests must be in writing. The physician office must fax a written request on their letterhead to Mainland Medical Center 6801 Emmett F. medical records)upon request. Use these sample letters to guide you on the release and transfer of medical records. Contact the …Requesting Your ARC Medical Records For Patients. As indicated on the form, specific authorization is required for the release of information about certain sensitive conditions, including: If you reside in Brazoria County and need copies of records, please contact our UTMB Angleton Danbury Campus at (979) 848-9140 or you may fax your request for records to (979) 849-2912. please use the appropriate form listed in the column to the right, complete the requested information, sign the form, and mail it or hand carry it to the following address. The "JPS Authorization and Request" form (Download in English, or, Download in Spanish) included fulfills all these requirements when properly completed. The template contains the personal information, limitations on the information, the release purpose, and the legal statement of the medical record release. 1052 or mail to: Covenant Medical Center Attn: Medical Records 3615 19th Street Lubbock, TX 79410. The sample medical records release form below details an agreement among the patient, ‘Thomas E Beckman’, the person who will releasing the information, ‘Jeane R Gano’, and the person who will be receiving the information, ‘Mark T Landis. Social Security typically requests your records by mail; this is then forwarded to Healthport for processing. Texas Children's may form that complies with HIPAA, the Texas Medical Privacy Act, and . This form is used to request copies of medical records. Mail. For copies of a medical record please contact: The University of Texas Medical BranchRequesting Your ARC Medical Records For Patients. Form 2076, Authorization to Release Medical Information Form Retention. e. If requesting a copy of the individual's health records with this form, state and federal law. I understand there is a charge for photocopies and records provided on electronic media, as permitted by Texas law, unless copiesVA » Health Care » South Texas Veterans Health Care System (STVHCS) » Patient Information » Request Your Medical Records South Texas Veterans Health Care System (STVHCS) MenuThe Medical Records / Health Information Management Department main number is (817) 347-5883. Third party information is protected. Release of Information. An invoice will be sent to the email or fax number provided above. 772. Medical record personnel are available to process requests Monday through Friday 8:00 a. . When is this form to be completed? Each time medical records are requested, Texas MedClinic (TMC) and TMC Provider. tx. The Medical Records / Health Information Management Department main number is (817) 347-5883. Social Security Disability. Date of Birth * Phone Number * By submitting this request you acknowledge that payment is required prior to release of records. or retention of a power of attorney, certain records are available(i. Fax the completed form, along with a copy of your I. Patient Name * Patient Address . Authorization forms may be brought to the department, mailed or faxed to the address or fax number located at the bottom of the authorization. g. Lowry Expressway Texas City, TX 77591 Telephone: (409) 938-5000. The Health Information Management Department (HIM) at UTMB is dedicated to maintaining your medical records and keeping your health information private and secure in accordance with federal and state regulations. The patient can request their health information and/or discharge instructions in an electronic format. When a child is born at the Medical City McKinney birth certificate information is submitted by a Birth Registrar to the Texas Department of Vital Statistics. For copies of a medical record please contact: The University of Texas Medical BranchTo Request a Copy of Your Medical Records: 1) Complete the attached form “Authorization to Use and Disclose Protected Health Information. us) has authority to license and regulate the records of physicians in the State of Texas. , Suite 3-810 Copies of medical records can be obtained through the TMC Health Information Management (HIM) Department. Medical Records. VA » Health Care » VA North Texas Health Care System » Patient Information » Request Your Medical Records Request Your Medical Records. For after-hours/weekend information, contact the HIM Request …To Request a Copy of Your Medical Records: 1) Complete the attached form “Authorization to Use and Disclose Protected Health Information. [Identify records requested, e. Getting Copies of Your Medical Records If you would like a copy of your record, we will be glad to help you complete a written request located in our department. Copies of Medical Records. Mail authorization form to The Medical Records Department will complete any unfinished information, obtain signature/signatures, and file the certificate with the State of Texas. Download Texas Medical Records Request Form for Free . Texas Children’s may verify your identity/guardianship. Download a copy of the release of information. Discharge & BillingTo request a copy of your medical records for personal use: Fill out an authorization form, and ensure all grayed-out portions are complete Mail or fax the completed form along with a …Patient Records Access Your Patient History. Individuals requesting medical records must present a government-issued photo ID at the time of pickup. State law allows a patient to obtain a copy of his records, or ask that a copy be sent to a new Please download the Authorization for Release of Patient Information, below, complete all required fields, sign it, and mail the form to: Texas Health Resources(a) Release of Records Pursuant to Written Request. 1965. by the Texas Health and Safety Code, Chapter 241, Section 241. ? Mail a written request for records to the physician by certified mail, return receipt requested. To request a copy of your medical records, please complete the: Release of Information Form, orRequests for Workers' Compensation Claim File Information Information in or derived from a claim file regarding a Workers' compensation claimant is confidential and may not be disclosed except as provided in the Texas Workers' Compensation Act. We will be happy to mail or fax you a form. For more information, view the instructions for completing the medical records request form. 524(b)(1), the entity holding the records may require that the request is made in writing. Hit enter to expand a main menu option (Health, Benefits, etc). How to Request Copies of your Medical Records Active Duty/CAC Card Holders: Any request from a patient for disclosure of information or documents from his or her own medical record must be requested utilizing the DD Form 2870 (Authorization for Disclosure of Medical or Dental Information); once completed, digitally sign Block 11. 13603 Michel Road, Tomball, Sample Medical Record Forms. You may fax the information to (469) 484-2006. Luke's Health Medical Records Department located at one of the following hospitals, or you can mail it. m. A Medical Records Request can get you your important documents so can switch doctors, see a specialist, or simply get copies for your own records. Office phone number: 214-456-2509 Office Hours: Monday – Friday 8 a. Fees/Charges for Open Records Requests. If you already work with us and need to update your Tax ID (TIN), do not use this form. Subpoenas for Medical Records April 2003 The following is a general description of the law in this area; your facts may a request for production, of other instrument issued The Texas State Board of Medical Examiners set rules for the fees we can charge for copying medical records. ’ Sample Medical Record Forms. and 5:00 p. Completed authorization forms may be submitted to UTMB by mail or fax. Mailing address: University of Texas Medical Branch Most practices or facilities will ask you to fill out a form to request your medical records. To request copies of your medical records, please download, complete and sign an Authorization for Release of Information form available on this page. The information included in this testimonial is based on one patient’s unique experience and is not intended to represent all patient outcomes or expectations. Baylor Scott & White Medical Center If the requestor wishes to maintain the request for confidential information, TSBDE will seek a determination by the Attorney General of Texas as to whether or not it may disclose or withhold the requested information. How to Request Information. RECORDS ARE PROTECTED UNDER FEDERAL PRIVACY ACT. Medical Records Request. 2. 54; 11 to 60 pages - $1. Submitting An Authorization. Please be sure to include your telephone number so we can Complete a Patient Access Request/Authorization Form. Submit the completed authorization form in person, by fax or mail to the appropriate Medical Records Department where you received your care and treatment. The forms can be usually be collected at the office or delivered by fax, postal service, or email, If the office doesn't have a form, you can write a letter to make your request. Requests for medical records must be made in writing. Access and download these helpful BCBSTX health care provider forms. The same process will be followed as with a request for personal use. AGTX Form 74 30 Jun 11 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE ~For physicians or health care facilities not affiliated with Memorial Hermann, you can request that we transfer your medical records by completing the Patient Request To Have Medical Records Transferred To Another Health Care Provider form and fax it …Please switch auto forms mode to off. Therefore, use the Standard Form and use the How to Write section of this page in order to enter the specific fields required to complete. The information you are seeking may be available on the TEA website or through one of the contacts listed above. Paper Records Search Fee : $21. O. and email to A fee will be incurred for this request. NOTICE: Please check the Texas Medical Board web site for current updates on its rules and policies with respect to these issues. Blue Cross Blue Shield of Texas is committed to giving health care providers with the support and assistance they need. To receive copies of medical records, download the Medical Records Request form and mail the completed form to: Release of Information The fees for copying records are set by the state of Texas and are reviewed for changes annually. ited to, all records and other information regarding health history, treatment, hospitalization, tests, and outpatient care, and also educational records that may contain health information. Each time medical records are requested, Texas MedClinic (TMC) and TMC Provider Group, PLLC (TMC PG) require documentation of the request to meet the requirements of the Health Insurance Portability and Accountability Act (HIPAA). We have partnered with ChartSwap, a web utility that allows us to exchange billing documents, affidavits, etc. Copies of Medical Records. This Texas Medical Records Request Form is in a relatively simple form. Only patients or their legal representatives may make a medical record request. state. Complete, sign and date the form. The Release of Information Department complies with applicable laws related to privacy practices and procedures when using or disclosing information. Request for Medical Records . To request a copy of a medical record, complete the Medical Record Request form and submit the form via ChartSwap. the physician transmits health information in electronic form, the physician may be subject to the and Human Services (if the physician is subject to HIPAA) and the Texas Medical Board. MyMCH Records. Understanding your health records is key to making informed health decisions. Birth CertificateMedical Records. For your convenience there are several ways to submit your medical records request: 1. If you or your physician needs copies of your medical records, please submit our Medical Records Release Form and allow 3-5 business days for processing. Some requests may be subject to a reasonable fee. To obtain a copy of your medical records, please complete the Authorization to Release Health Information form (Autorización para Revelar Información Médica Protegida (PHI)) and provide a copy of your driver's license. You can deliver the form in person to a CHI St. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION and the payment of my health care will not be affected if I do not sign this form. Completion of this form allows UT Physicians to transfer the medical record in compliance with the requirements for protection of patient health care information (HIPAA). , Monday through Friday. Request a Referral. (For your convenience we provide our patient forms online. The San Antonio Record Service is open Monday through Friday, 8 a. ” a. RECORDS AREMedical Record Copies. To request copies of your medical records, please complete the attached authorization form and mail or fax with a copy of your driver’s license to the address below. OR. Send the complete form by mail or fax, or you can likely try to deliver it in person to the medical record office. Medical Records Request Form This form is used to request copies of medical records. TEXAS ORTHOPAEDIC AND SPORTS MEDICINE. Texas 75088 Phone: 972. Physician offices or other health care providers may request a copy of medical records by faxing the request on office letterhead to (256) 265-8484 or (256) 265-8131. As a patient, you have the right to inspect or review your medical records. For physicians or health care facilities not affiliated with Memorial Hermann, you can request that we transfer your medical records by completing the Patient Request To Have Medical Records Transferred To Another Health Care Provider form and fax it …If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. Print and complete the Medical Records Release Form. The Billing Office at Baptist Hospitals of Southeast Texas is here to provide helpful answers and information. 30 Sep 2016 If a standard governing access to your medical records under Texas law If you request a copy of your medical records in paper form, Texas 12 Jul 2016 Tip: Designate one day a week, like Friday, to provide records to patients who have filled out a medical records release form that week. Medical Records Department University Medical Center of El Paso 4815 Alameda Avenue El Paso, TX 79905. In order to legally request medical records, in accordance with 45 CFR 164. List the dates of service you are requesting. The requested We require identification before we will release your records even to you. 53 per page Requesting Medical Records. What is a D. 00 The University of Texas Medical Branch. Patients may also request a copy of medical records by mail or in person. The Medical Records staff will then verify the patient has a medical record. Sometimes patients send a written request for records to the doctor’s next of kin or the executor of the doctor’s estate. Home / Rush Fee : $20. 1131 Option 1 Fax: Baylor Scott & White Medical Center – Round Rock Health Information Management Department 300 University Blvd. This method provides assurance that the request was delivered. Request for TWC Records or To obtain your own records, you will need to provide proof of identification such as a copy of your government-issued photo ID. Patients will need to complete an Authorization for Use/Disclosure of Protected Health Information form. If the patient is requesting the records, there will be a fee. Medical Records Authorizations Providence Health & Services provides access to medical records from our hospitals and other medical facilities to patients and their authorized representatives. Court. To request a copy of your medical records for another physician Fill out an Authorization Form – ensure all grayed out portions are completed Specify the …Your request will be processed and mailed to address on the authorization form, or you may call to arrange pick up. DeBakey VA Medical Center Release of Information Office 2002 Holcombe Blvd. If the requested records are stored in microfilm form, Can I request an amendment to my medical records? If the change is for misspelling of your name or insurance information, please call (713) 448-5502. Please print. Copies of your health records will be provided upon written request and for a reasonable fee. and mail the form to the Medical Records Department of USMD Hospital at Arlington. A copy of your newborn’s Birth Certificate can be obtained from the Denton County Clerk’s Office located at 400 N. Medical Records Request Form. Other names for this document: Medical Records Request Form, Letter to Request Medical RecordsCopies of Medical Records. And if you need something different, you can create your own legal forms and letters from MR8’s the request for production of Medical records pertaining to Timothy Beale, DOB 03/26/1953, Billing & Medical Records Information about Beaumont Hospital Services. Forms must be printed out, completed, signed by the patient and submitted along with a copy of the patient’s driver’s license. 43 per page; Texas 76017 • …To request copies of your medical records, print out and complete the medical records request form and mail it with a copy of your driver’s license to the address listed below: Harris County Sheriff’s Office – Attn: Medical Records – 1200 Baker Street, Houston Texas 77002. via a secure internet connection. To request your records, start by contacting or visiting your provider’s health information management (HIM) department—sometimes called the medical records or health information services department. Medical. Other names for this document: Medical Records Request Form, Letter to Request Medical RecordsThree Steps to Request Your Medical Records DOWNLOAD an Authorization for the Use or Disclosure of Health Information Form COMPLETE the form, being sure to DESIGNATE whether you would like to receive your medical records by paper (through the postal mail) or electronically (through a secure link that will be emailed to you). You can also see where your doctor went to medical school and whether your doctor has been disciplined by the Texas Medical Board. Request Your Medical Records. Why can’tFind out how to use these forms to transfer or request copies of your medical records at Kaiser Permanente Washington Transfer and get copies of your medical records You have the right to view or get copies of your medical record (or your child's) for free. tmb. Medical City Fort Worth utilizes the services of CIOX to handle the fulfillment of all requests for medical records. Medical Records. form that complies with HIPAA, the Texas Medical Privacy Act, and . Request Medication Refills. Medical records are stored at the cancer center where you received treatment. To request medical records of past hospital stays or surgeries in a Methodist Healthcare facility and to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations, please fill out the form below. You can mail or fax to Healthport with a copy of your driver’s license to: San Antonio Shared Services CenterMedical Records. The Texas Medical Practice Act/Texas Occupations Code provides addt'l guidance on confidentiality and info copies of billing records pertaining to medical treatment of a patient unless specifically requested pursuant to the request for release of medical records. You save time and reduce errors. A patient may also contact the TMB to determine if a custodian of records has been reported. 412. us ) has the authority to license and regulate the records of dentists in the State of Texas. Medical Record Copies. ] [Note: HIPAA also allows you to request a summary of your medical records. Delivery times are from the date payment is received. To request information from TEA, submit your request: Online to: Online Request Form, which sends requests directly to the designated PIR email address. Darnall Army Medical Center (CRDAMC) is dedicated to providing the medical information our customers need while protecting our patients’ privacy and ensuring each request is releasable in accordance with State and Federal laws. To Request a Copy of Your Medical Records: 1) Complete the attached form “Authorization to Use and Disclose Protected Health Information. Please read TSBDE Rule 102. To request a copy or have a copy of the medical record sent to another party, call Cook Children's Release of Information department in the main medical center building at 682-885-1012 between the hours of 7:30 a. Dallas, Texas 75235. A patient or his/her legal representative may request a copy of his/her medical record, or for a copy to be sent to another party, by completing a Release of Information form. Cypress Fairbanks Medical Center Houston / Cypress Fairbanks Medical Center Hospital Houston, TX 77065 Medical Records Request to Release Information Fax: (281) 949-3913. ). The State Board of Dental Examiners ( www. Please bring the completed form(s) with you to your appointment. To have a copy of your medical records sent to another medical facility or to obtain a copy for personal reasons*, please complete the following steps: When I complete the authorization/request for records form, how long is …Request a Copy of Your Medical Record. To request a medical record, please one of the forms listed in the column to the right, complete the requested information, sign the form, and mail it to the following address — Central Texas Veterans Health Care System Release of Information (136F) 1901 Veterans Memorial Drive Temple, TX 76504. , automatically fill into the selected form, eliminating re-keying. Utah. Please download the Authorization for Release of Patient Information, below, complete all required fields, sign it, and mail the form to: Texas Health ResourcesWith certain exceptions, the release of medical records is prohibited by the ad litem appointed for the patient, as authorized by the Texas Mental Health Act, the The form may be used to obtain information from other providers and when MAIL OR FAX THIS FORM TO: ATTN: MEDICAL RECORDS DEPARTMENT. Birth Certificates. to 5 p. to (210) 271-1978. State-by-State Guide of Medical Record Copying Fees. Please complete this form if you are interested in joining the Aetna's network. Valley Parkway, Suite 2094, Lewisville, Texas…or retention of a power of attorney, certain records are available(i. - Be informed about open records laws and educate employees on the requirements of those laws; - to any written estimate of charges within 10 business days of the date the governmental body sent it or the request is considered automatically withdrawn. Baylor Scott & White Medical Center – Grapevine. Sample Clause …Medical Records Request Form This form is used to request copies of medical records. 00 (only if request is fulfilled and records are delivered within 48 hours) X-rays and other media : Reasonable costs not to exceed $25. Provided in Paper Form: 1 to 10 pages - $42. Complete a medical records Release of Information Form: A HIPAA-compliant Release of Information Form is required whenever you request copies of your medical record. Medical Records Release Form PDF Sample. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals. New Patients Registration Download Download Spanish Medical history DownloadTo request a copy of your medical records for personal use Fill out an Authorization Form – ensure all grayed out portions are completed Mail or fax with a copy of a valid state issued photo IDYour request will be processed and mailed to address on the authorization form, or you may call to arrange pick up. You may also fax your form to 214-456-6170. At this time there is no centralized state repository for medical records. Central Texas Jun 02, 2017 · Release of Information The Release of Information (ROI) office at Carl R. Medical Records and Release of Information. AGTX Form 74 30 Jun 11 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE ~To Request a Copy of Your Medical Records: 1) Complete the attached form “Authorization to Use and Disclose Protected Health Information. 16 Pages 1 - 40 : $0. Medical Records Request Form Patient Information. (c) For purposes of Subsection (a), the executive commissioner, in consultation with the department, the Texas Medical Board, and the Texas Department of Insurance, by rule may recommend a standard electronic format for the release of requested health records. Texas Board of Veterinary Medical Examiners 333 Guadalupe St. to 4:30 p. The completed form may also be faxed to 956-289-2964 . Why can’tPlease switch auto forms mode to off. We do not release confidential information over the phone. Request copies of medical records in person. Select Forms > Downloadable Forms to request medical records. Please call and speak to a representative before mailing or delivering your request form if you should have any questions. Copy Fee Charges . There will be a fee charged for records based on the number of pages released and in accordance with the Texas Department of State Health. Retention is the same as required for the entire case record. ENROLLMENT & ACADEMIC SERVICES OFFICE OF THE REGISTRAR Records Request Form Requested Records Request should be sent by:Department of Insurance, the Texas Health and Human Services Commission, or the patient’s or subscriber’s employer. …Medical Records Request When it comes to personal information, we want to protect your privacy. Set Up Your Personal Health Record. Houston, Texas …You may request your medical records for any South Texas Health System facility at any location. Texas Children's may Jul 12, 2016 Tip: Designate one day a week, like Friday, to provide records to patients who have filled out a medical records release form that week. Medical Records page of the DSHS Records Management Office web site The Texas Medical Board and claims to fully document services and supplies provided to a Medicaid client must be made available promptly upon request from the Texas Department of State Health Services, Texas Attorney General's Medicaid Fraud Control Unit, NHIC Medical Records Request Form When is this form to be completed? Each time medical records are requested, Texas MedClinic (TMC) and TMC Provider Group, PLLC (TMC PG) require documentation of the request to meet the requirements of the Health Insurance Portability and Accountability Act (HIPAA). New Patients Registration Download Download Spanish Medical history DownloadYou'll need to fill out and sign this form to request records from University of Texas MD Anderson Cancer Center. The Medical Records / Health Information Management (HIM) Department main number is (972) 519-1225. Michael E. You'll need to fill out and sign this form to request records from University of Texas MD Anderson Cancer Center. 725. As a courtesy, your primary doctor will be notified of your request to inspect and/or review your medical …Texas Medical Center 6411 Fannin F: (713) 704-0136 P: (713) 704-2162. I understand there is a charge for photocopies and records provided on electronic media, as permitted by Texas law, unless copiesVA » Health Care » South Texas Veterans Health Care System (STVHCS) » Patient Information » Request Your Medical Records South Texas Veterans Health Care System (STVHCS) MenuRequest Medical Records. The hospital’s address can be found at the bottom of the form. MR8 sample forms & letters etc. You can find practical, colorful files in Word, Excel, PowerPoint and PDF formats. 2 for all costs associated with open records requests. Disputes & Appeals Overview; Print; Share; medical records and office notes) Find dispute and appeal forms. You may mail a written request to the address below, which should contain as much information as possible to assist us in identifying your record(s). Breadcrumb. Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standard Prior Authorization Request Form for Health Care Services if the plan requires prior authorization of a health care service. Fees. Detailed Instructions. To request copies of your medical records, print out and complete the medical records request form and mail it with a copy of your driver’s license to the address listed below: Harris County Sheriff’s Office – Attn: Medical Records – 1200 Baker Street, Houston Texas 77002. Moving patient charts from paper to electronic form. Within 30 business days of receiving the request if …Medical Records Release Form 50 Document(s) Medical Release Form 101 Document(s) Medical Consent Form 5 Document(s) DOT Physical Form 2 Document(s) BSA Medical Form 3 Document(s) Medical Application Form 4 Document(s) Generic Authorization Medical Release Form 8 Document(s) Immunization Record 5 Document(s) Medical Records Request Form 8 You can request a copy of your medical records by completing a release form. tsbde. Upon leaving the hospital, you may have questions about what you are being charged for and how the services will appear on a billing statement. D. By mail or in person to: Texas Education Agency Public Information OfficeREQUEST FOR TEXAS NATIONAL GUARD RECORDS Adjutant General’s Department ATTN: James Shive, Customer Service NGB Form 22 DD FORM 214 DA Form 2-1 Retirement Points Test Scores (ASVAB) certain records are available(i. Within 3-5 business days of receiving the request. Cook Children's has more than 60 locations across North Texas, because even when your child's diagnosis is complicated, finding the right care should be simple. your healthcare provider can request records. A reasonable fee for providing copies of medical records in electronic format is a charge of Learn how to request your child's medical records, and find contact information for our Health Information Management department. Joining MyMCHRecords is free and easy! Request Lab or Test Results. Complete this form to request to terminate or revoke restrictions currently in place for use or disclosure of your Protected Health Information. Fax to 806. MyMCHRecords is a convenient online service available to anyone who has received care through Medical Center Health System facilities and doctors. – 5 p. Galveston, Texas 77555-0782 409. Request Medical Records by …To request a copy of your medical records, call Cook Children's Release of Information Department in the main medical center building at 682-885-1012. The medical record information release (HIPAA), also known as the 'Health Insurance Portability and Accountability Act', is included in each person's medical file This form is used to request copies of medical records. Your medical records will be mailed to you or you may pick them up from our department located on the second medical records processing fee for patients: $25 Request Processing Fee per request + $8 per imaging CD copy (x-ray, MRI) Fees apply to patients requesting records for themselves or directing records to any third party (doctor, attorney, insurance company, etc. Download and complete the Release of Information form by clicking here. Birth CertificateFor copies of a medical record please contact: The University of Texas Medical Branch Department of Health Information Management Release of Information Section 301 University Blvd. The medical record information release (HIPAA), also known as the 'Health Insurance Portability and Accountability Act', is included in each person's medical file Medical Records Request Form. Use the Request for Texas Workforce Commission (TWC) Records form and follow the instructions. Have dispute process questions? Read our dispute process FAQs. In order to legally request medical records, in accordance with 45 CFR 164. To obtain a copy of your medical records, please complete the Authorization to Release Health Information form and provide a copy of your driver's license. Medical Records Request Form By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the person(s) or entity listed below. 154. The form must be filled out completely, and it must be signed and dated by the patient or patient’s legal guardian (legal proof is required). To obtain a copy of your medical records, you will need to complete this form. The health care provider or health plan must respond to your request. The Texas Medical Board (www. Request Paper Copy of Medical Records. 3380 ex. I request copies of the following [or all] health records related to my treatment