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.
The date(s) of service (date procedure or consultation was made)
The individual or entity to whom the information is to be released
The type of records to be released
The purpose of the request (why the information is needed)
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 or postal services. Call (956) 362-3451 for assistance. You may complete the form and send back via fax to (956) 362-3450 or postal services:
The requested copies of medical records shall be furnished by the hospital/physician within 15 days after the date of receipt of the request and resonable fees for furnishing the information.
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.
