Are you requesting medical records for yourself or on behalf of someone else?
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Yes, for myself
Yes, on behalf of someone else
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If you are requesting medical records for yourself, please call 214-871-7000 or fax 214-871-7020
Patient Name
Patient DOB
-
Month
-
Day
Year
Date
Email
example@example.com
What records are needed? ($25 Fee Required)
Medical
Billing
Radiology
All Records
Certification of Records (has no fee unless it needs to be notarized)
Additional Specialized Fees
Digital X-Ray Images CD: $8 (fee includes ALL images)
Notary fee: $6 (fee includes ALL notarized pages)
Affidavits: $15 (fee includes ALL Affidavits)
Upload Documents
Browse Files
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What date range would you like records for?
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Total
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Form of Payment
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next
( X )
USD
Total Fee(s)
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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