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 whom the information is to be disclosed.
The "JPS Authorization and Request" form 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: 817-921-9671
It is not possible to accept electronic transfer of this form at this time.
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 60
$1.43 per page
- Pages 61 through 400
$0.71 per page
- Each remaining page
$0.37 per page
If the information has been microfilmed
Click here for Authorization Form