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  • Echo Request Form - Texas Children's Hospital

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Texas Children s Hospital Medical Center Echocardiogram Request Form West Tower 20th floor To schedule an echocardiogram appointment please complete this form and fax to 832-825-5691 if form is not complete we will not process the appt. Patients under 15kgs and under 3 years of age are sedated a sedation order is required* Please request the second page from our office. DEMOGRAPHIC INFORMATION PLEASE PRINT CLEARLY Patient Name DOB SS Gender Male / Female Race Address City/State/Zip Home/Cell Insurance policyholder DOB SS Relationship Employer Wk Ph Insurance HMO / PPO / POS Benefits Address City/State/Zip Policy ID Group Emergency Contact Tel Relationship PCP Contact/Nurse Tel Fax Sedation Required Yes No Physician Signature Only patients under 3 years old sedation order form required* Please obtain form from our office. DIAGNOSIS CARDIAC REASON FOR ECHO If an insurance authorization is required appt. will not be made Sugarland 281-494-7010 Clear Lake 281-282-1900 Woodlands 936-321-080....

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The Department of State Health Services is committed to providing full access to public information. To request records under the Texas Public Information Act: Submit a request in writing via U.S. Mail, fax or email. Include contact information and a clear description of the records you are requesting.

If you are under 18, a parent will need to help you request your medical record. First call Medical Records at Texas Children's Hospital at 832-824-1600. They will get you the forms you need to allow your medical record to be sent to your new health care provider.

Texas Laws for Adults' Medical Record Retention A licensed physician shall maintain adequate medical records of a patient for a minimum of seven years from the anniversary date of the date of last treatment by the physician.

As an Accredited Pediatric Heart Failure Institute, Texas Children's Heart Center provides a multi-faceted continuum of care for children with cardiac issues and heart failure, including: Arrhythmia surveillance. Cardiovascular genetic testing and research. Cardiac intensive care.

A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc.

To schedule an appointment, please call 832-824-3278 (Houston area) or 737-220-8200 (Austin area), Mon. – Fri., 8 a.m. – 5 p.m. Thank you for allowing us to care for your child.

Request your medical records To receive a copy of a medical record, you must complete a Release of Information form (English and Spanish). Be very specific about the information you need to have released. Indicate dates of service, types of visits and what parts of the record you need.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232