Please complete in full, print, and sign the appropriate attached Medical / Shot Record Release forms to have our office release records to you.

We are happy to forward medical records one time as a courtesy without charge to another physicians office. However, should you need additional copies or request records forwarded to you there will be a minimum charge of $25.

Normally records can be provided within 2 weeks


Please fax completed form to 972-331-7201

*Requires Adobe Acrobat Reader. which you may download for free.
 
 

Request and Authorization Forms
 
"Medical Record Release Forms"
PF-3300 Authorization of Disclosure of PHI by Another Covered Entity for Use by Clinical Pediatric Associates of North Texas

 
 
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