www.houstondermatologyassociates.com - Medical Records Request Form

MEDICAL RECORDS REQUEST
Name

First NameLast Name
I {name} hereby authorize and request of:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
to forward a copy of summary of the following medical records:
for dates of service from Date to Date
To
Mailing Address:

6560 Fannin, Suite 1720, Houston, TX 77030
Name of Patient (Print)

First NameLast Name
Patient’s Date of Birth

MonthDayYear
Patients Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: