Memorial-610 Hospital for Animals

910 Antoine Drive
Houston, TX 77024

(713)688-0387

www.mem610.com

Medical Records Request Form


This form is to request copies of medical records. Only clients or their legal representatives may make a medical record request. Memorial-610 Hospital for Animals may verify your identity. Requests may be subject to a reasonable fee.
Client Name (required)

Patient Name (required)

Species (required)

Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

Description of information requested (mark all that apply):
Dates of Service
Dates (Start - End) (required)

Vaccination History
Laboratory Results
Imaging Reports/Studies (Radiographs, US)
Entire Medical Record
Purpose of Disclosure (select one):
Boarding/Grooming/Training
Continuing Medical Care
Insurance Claims/Payment of Bills
Other


I want to request medical records to be sent to the third-party I have indicated below. My completion of this form serves as authorization for Memorial-610 Hospital for Animals to disclose these records to this person or group. I understand that once my information leaves Memorial-610 Hospital for Animals, Memorial-610 Hospital for Animals is no longer able to protect the information, and the recipients of my information may not be legally required to protect my information.
Name (required)

Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

Fax

Email (required)


I understand this authorization may be revoked in writing at any time, except to the extent that action had already been taken in reliance on this authorization. This authorization expires
(insert date or applicable event)


on or within 180 days or the date of authorization, whichever is greater.
Signature (required)

Date (required)


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