Patient Release Forms

• Authorization to Release Protected Health Information
• Autorización para Revelar Información Médica Protegida

Request for Medical Records

1. To request copies of your medical records, print and complete the Authorization for Use and Disclosure of Protected Health Information form below.
2. Mail or fax the completed form using the information listed below.
3. To release medical record copies to a physician or another third-party, follow the instructions in Step 1 above.
4. Medical record copies can be released electronically, via email or on paper.
5. You may ask questions about releasing your information by calling COIX at (888) 749-7952.
6. Follow these instructions for completing the Authorization for Use or Disclosure of Protected Health Information.
7. Requests for medical record copies are completed by COIX.

Send completed forms to:

Medical City Dallas Hospital – Release of Information
160 Imperial Boulevard
Hendersonville, TN 37075-3440

Phone: 1-888-749-7952
Fax: 469-484-2006