- Authorization to Release Protected Health Information
- Autorización para Revelar Información Médica Protegida
Request for Medical Records
- To request copies of your medical records, print and complete the Authorization for Use and Disclosure of Protected Health Information form below.
- Mail or fax the completed form using the information listed below.
- To release medical record copies to a physician or another third-party, follow the instructions in Step 1 above.
- Medical record copies can be released electronically, via email or on paper.
- You may ask questions about releasing your information by calling COIX at (888) 749-7952.
- Follow these instructions for completing the Authorization for Use or Disclosure of Protected Health Information.
- Requests for medical record copies are completed by COIX.
Authorization to Use or Disclose Protected Health Information (PHI) Forms: English | Spanish
Send completed forms to:
Medical City Dallas Hospital – Release of Information
10030 N. MacArthur Blvd.
Irving, Texas 75063