This form is a consent to the release of medical history. The patient authorizes the release of his/her medical history to the specified party within the consent release form. The form also provides that all prior authorizations are cancelled.
Consent Form For Release Of Information In San Antonio
State:
Multi-State
City:
San Antonio
Control #:
US-00460
Format:
Word;
Rich Text
Instant download
Description
Free preview
Form popularity
FAQ
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.
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.
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.
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.