We've moved! Our main office is now at 8801 N. Tarrant Pkwy, North Richland Hills.
Patient Forms

Medical Records Request

Complete the authorization below to have your records released. Every section marked required must be filled in for the authorization to be valid.

1 About You

The patient whose records are being released.

Maiden name, previous legal name, etc.
Optional.
2 Releasing Your Records

This is us. Nothing to fill in.

360 Cardiac Care

8801 N. Tarrant Pkwy
North Richland Hills, TX 76182

Phone (682) 337-3810  ·  Fax 682.337.3817

3 Who Can Receive Your Records

The person or organization you want us to send the records to.

4 Reason for Disclosure

Choose one.

5 What Can Be Released

Check everything you want released. If you want everything, check the first box only.

6 Sensitive Records

These are never released unless you initial them here, even if you checked "All health information" above. Leave blank to keep them private.

7 How Long This Lasts

This authorization stays valid until you withdraw it in writing, until the patient reaches the age of majority, or until the patient's death, whichever comes first. You may also set an earlier end date.

Optional.
8 Signature

I have read this form and agree to the uses and disclosures described. I understand I can withdraw my permission at any time by giving written notice to the person or organization named above, and that withdrawing it does not undo anything already released. I understand that information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by federal or state privacy laws.

Sign above using your mouse, finger, or stylus. Please sign before continuing.

Today's date is applied automatically.
Only if you are signing on behalf of the patient.

Minor Patient's Signature

A minor patient must also sign to release certain records, including reproductive care, sexually transmitted diseases, drug or alcohol treatment, and mental health treatment (Tex. Fam. Code ยง 32.003).

You will see the completed form and can check it before anything is sent.