Medical Records Request

Because an actual signature is required to release medical records information, personnel at USMD Hospital at Fort Worth are not allowed to process requests or authorizations received via e-mail. Please download the Authorization for Release of Patient Information, complete all required fields, sign it, and mail the form to the Medical Records Department of USMD Hospital at Fort Worth. The hospital’s address can be found at the bottom of the form.

Fees

Provided in Paper Form:

  • 1 to 10 pages - $42.54
  • 11 to 60 pages - $1.43 per page
  • 61 to 400 pages - $0.71 per page
  • More than 400 pages - $0.37 per page

Provided to Patient (no charge for continuing care) (If requesting for Disability/Worker's Comp, there is no charge, but patient must show proof of appointment/hearing)

  • 1 to 10 pages - Complimentary
  • 11 to 50 pages - $0.50 per page
  • 51 or more pages - $0.20 per page

Exceptions 

Local, state or federal agencies requesting health care information may be entitled by statute to a different fee. The agency should inform the hospital of this fact, or information can be obtained from the Legal Department.

Other Charges

The hospital may charge a reasonable fee for:

  1. Execution of an affidavit or certification of a document, not to exceed the charge authorized by Civil Practice and Remedies Code, §22.004; and
  2. Written responses to a written set of questions, not to exceed $10.00 for a set.

A physician-owned hospital.

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