Medical Record Copies

INSTRUCTIONS TO OBTAIN HEALTH CARE (Medical Record) INFORMATION 

In the State of Texas, a written authorization signed by the patient or the patient's legally authorized representative is required prior to disclosure of health care information. An authorization is valid only if it:

  • is in writing;
  • is dated and signed by the patient or legally authorized representative;
  • identifies the information to be disclosed; and
  • identifies the person or entity to which the information is to be disclosed.

The "JPS Authorization and Request" form (Download in English, or, Download in Spanish) included fulfills all these requirements when properly completed.

The properly completed Authorization and Request form may be mailed to:

JPS Health Network
Attn: Health Information Management
1500 S. Main
Fort Worth, TX 76104

Or sent via fax to: 817-702-4948

 

Healthcare providers (physicians, hospitals, etc.) requesting patient information for continuity of care purposes should fax their request to 817-926-7324. 

 

Questions? Contact Medical Records: 817-927-1011 

   

It is not possible to accept electronic transfer of this form at this time.
Individuals requesting medical records must present a government-issued photo ID at the time of pickup.

NOTE: There is a charge for copies of health care information unless information is being provided directly to another health care provider (doctor's office, hospital, etc.)

Current Charges for Patients or their Legally Authorized Representative 

  • Pages 1 through 10 - $45.02
  • Pages 11 through 60 - $1.51 per page
  • Pages 61 through 400 - $0.75 per page
  • Each remaining page - $0.40 per page

If the information has been microfilmed

  • Pages 1 through 10 - $68.58
  • Remaining Pages - $1.51 per page

If the information is stored digitally or electronically AND requested in digital or electronic form

  • Flat Fee - $81.57

Authorization Form : (Download in English, or, Download in Spanish)