Records Request Form

Records Request
Thank you for contacting the North Texas Behavioral Health Authority for records requests. Once we receive your request, we will review it and respond within 3 business days for communication and any clarification if needed. If this is an urgent matter, please e-mail or call our Quality Management Department at qm@ntbha.org or 833-392-4800.

(Note: Please complete this form fully before submitting it. Contact information is required [the form will not submit without it] and is important in case we need to confirm any information.)
Date

MonthDayYear
Date
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Name of the agency/provider or individual to whom the records will be disclosed:
In what format would you like the records shared?

faxede-mailedpicked up
If you selected "faxed" or "e-mailed" above, please enter contact information:
Fax number or E-mail address
Types of Protected Health Information (PHI) included in this request:

Physician/Medication OrdersPhysician Progress NotesPsychiatric EvaluationsLab/X-ray ReportsRecovery Plans/ReviewsCounseling NotesNursing NotesImmunization RecordsARDs/IEPsSchool Records/TranscriptsAssessmentsSubstance Use Disorder Counseling NotesOther
Date Range of Records Requested:
example: 01/01/2020 - 11/11/2024
Comments or Additional Instructions:
NOTE: If you are requesting disclosure of mental health information, then, the potential exists for the information described in this authorization to be re-disclosed by the recipient. If the information is re-disclosed, then it is no longer protected by medical privacy laws.

Substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and 45 CFR Parts 160 and 164 and, therefore, cannot be disclosed without express written consent unless otherwise provided for by the regulations.

If you are requesting as a parent/guardian/managing conservator of a minor or as a guardian of an adult, the information disclosed/used/received may contain references about you and your family.
Should be Empty: