Forms

Written Authorization

Requests for the release of medical records (protected health information) must be submitted in writing and must contain all the elements required by law.

Authorizations must also be dated and signed by the patient or the patient’s legally authorized representative. In the case of a minor, a parent or legal guardian must sign the authorization

English

Spanish

Instructions

DHR Health has the form available online or the form can be sent to you via fax/email if needed. Call 956-362-3451 for assistance. You may complete the form and send back via fax, email or postal services:

Please return the form with a copy of the patient’s driver’s license or government issued ID. Any individual who is authorized to receive the records on behalf of the patient will also be required to present a copy of ID.

Processing Fees

There may be a fee associated with the release of medical records and/or images on CD.

*DHR Health is not required to release the information requested until all fees are paid.

No fee is assessed when the information is being sent to another health care provider. Call 956-362-3451 for further details.