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
- identifies the person or entity to which the information is to be disclosed
|How To Request Patient Records|
|MyChart||You can request your records using your JPS MyChart account.
|You can send an email to firstname.lastname@example.org.
Please be specific in your email request as to what you are needing copies of. Please let us know where we need to send the records to, i.e., your physician's office, your return email address, and your physical address.
|Fax||You can fax a written request to 817-702-5700. A copy of our Authorization Form to release records is available on this page.|
|USPS Mail||A copy of our Authorization Form to release records is available on this page. You can complete it and mail it to:
JPS Health Network
Health Information Management
1500 S. Main Street
Fort Worth, TX 76104
The "JPS Authorization & Request" form fulfills all of the State of Texas requirements when properly completed.
|Download Form in English||Download Form in Spanish|
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.)
It is not possible to accept electronic transfer of this form at this time. Individuals requesting medical records must present a government-issued photo ID at the time of pickup.
Current Charges for Patients or their Legally Authorized Representative
- Pages 1 through 10 - $48.10
- Pages 11 through 60 - $1.62 per page
- Pages 61 through 400 - $0.79 per page
- Each remaining page - $0.43 per page
If the information has been microfilmed:
- Pages 1 through 10 - $73.27
- Remaining Pages - $1.67 per page
If the information is stored digitally or electronically AND requested in digital or electronic form:
- Flat Fee - $87.14
Healthcare providers requesting patient information for continuity of care purposes should fax their request to 817-926-7324.
Questions? Contact Medical Records: 817-702-1013