Medical Records Request

Complete the form below to request medical records, billing records, or related documentation.

Please provide complete and accurate information to help us identify the patient and locate the correct records.

Notice:

TXOSA cannot process or respond to a records request without a valid, HIPAA-compliant authorization signed by the patient or the patient’s authorized representative.
Any required authorization(s) must be submitted separately by email or fax. Please include the patient’s full name and date of birth so it can be matched to the corresponding request.
Third-party requestors must pay all applicable records-retrieval fees before the request can be completed and records can be released. Payment instructions will be provided after the submission is reviewed.
Submitting this form alone does not authorize the release of protected health information.

Medical Record Request

I am...

Your Name

Your Organization or Law Firm

Your Email Address

Your Phone Number

Patient’s Name

Patient’s Date of Birth

I am requesting…

Select all that apply.

Please describe the records you need.

Acknowledgment

I certify that the information provided is accurate and that I am the patient or am authorized to submit this request on the patient’s behalf. I understand that additional verification, documentation, patient authorization, or payment may be required before the request can be processed or completed.

If you are human, leave this field blank.