Request for medical record from Houston Family Physicians PA
Omer 713-492-0433 ext 8 Fax: 713-588-8600 email docs@texmedrevenue.com
Full name of patient you request the record
*
First Name
Last Name
Date of Birth of Patient
*
-
Month
-
Day
Year
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Your name
*
First Name
Last Name
Your Phone number
*
-
Area Code
Phone Number
Your fax number
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Area Code
Phone Number
E-mail (type not applicable if you dont have an email)
*
Please upload document with patient's signature approval of release patient medical record
Upload a File
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Medical record of patient
$
50.00
Mail Shipping Cost
$
20.00
Total
$
0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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