Get Tx Texas Childrens Medical Records Request Form 2021-2025

The TX Texas Childrens Medical Records Request Form is designed to facilitate the process of obtaining medical records for patients or their legal representatives. Filling out this form online can streamline your requests and ensure that you receive the necessary information efficiently.

Follow the steps to complete the form correctly and efficiently.

1. Press the ‘Get Form’ button to access the TX Texas Childrens Medical Records Request Form and open it in your preferred editor.
2. In Part 1, enter the patient's information including their name, date of birth, address, contact phone number, city, state, and ZIP code accurately.
3. Move to Part 2 to specify the protected health information you are requesting. Indicate the dates of service and select the type of information by checking the appropriate boxes; be mindful to check only relevant boxes.
4. In Part 3, provide specific authorization by checking any applicable boxes if you are requesting sensitive information such as psychiatric or genetic health records.
5. Complete Part 4 by selecting your preferred format for receiving the records. Options range from password protected CDs, paper copies, to electronic formats.
6. In Part 5, state the purpose for the release of records. Choose ‘Continuum of Care’ or specify another purpose.
7. If applicable, fill out Part 6 with information about any third party the records should be sent to, including their name, address, and fax number if necessary.
8. In Part 7, review the terms of authorization, understanding that this form may be revoked and include the expiration date for the authorization.
9. Finally, in Part 8, provide the necessary signatures. Ensure the signature of the patient or their legal representative is included, along with the printed name, date, and relationship to the patient.
10. After filling out the form, you may save your changes, download the completed form, print it for physical submission, or share it as needed.

Complete your TX Texas Childrens Medical Records Request Form online today for quick access to your medical records.