The releasor authorizes his/her employer to release employment references including, but limited to, his/her employment history and wages and any information which may be requested relative to his/her employment, employment applications, and other related matters, and to furnish copies of any and all records which the employer may have regarding his/her employment.
Release Of Information Form Template In San Antonio
Category:
State:
Multi-State
City:
San Antonio
Control #:
US-00458
Format:
Word;
Rich Text
Instant download
Description
Form popularity
FAQ
Release of information (ROI) allows patients to release information from their medical records to authorized individuals or organizations.
For immediate continuity of care requests, you or your health care provider can request that records are sent directly to their office. Use the form above, or your provider's office can fax a written request on business letterhead to 619-543-7128.
Visit the Open Records Portal to request an open record. It takes about 10 business days to receive a response to your open records request. To contact the Department of Communications & Engagement regarding open records, please call (210) 207-6149. The office is located at 115 Plaza De Armas San Antonio, Texas 78205.
Email: medical.records@utsouthwestern. Fax: 214-645-9141, Attention: UT Southwestern Medical Center Release of Information Department.
To request a copy of your medical records or to request that records be transferred to another facility, please contact UAB's Medical Records Department by calling (205) 930-6721 or faxing to (205) 930-6721.
By mail to the City: Open Records Division of the City of San Antonio, P.O. Box 839966, San Antonio, Texas 78283.
For UTHSA patients requesting records, please email your request to himroirequests@uthscsa, fax your request to (210) 450-6058, or mail it to the “HIM – Release of Information” address listed below.
View your patient medical record securely from your computer or mobile device through MyChart. Once logged in to MyChart, go to Menu > Document Center > Requested Records > Click to send a request for records and complete the form.
