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Medical Records Request

Because a manual signature is required to release medical records information, personnel at USMD Hospital at Arlington are not allowed to process requests or authorizations received via email. 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 Arlington. The hospital’s address can be found at the bottom of the form.

Fees

Medical records provided in paper format:

  • 1 – 10 pages: $52.12
  • 11 – 60 pages: $1.76 per page
  • 61 – 400 pages: $0.86 per page
  • More than 400 pages: $0.47 per page

A basic retrieval or processing fee, which must include the fee for providing the first 10 pages of copies and which may not exceed $52.12.

A charge for each page of:

  • $1.76 for the 11th through the 60th page of provided copies
  • $0.86 for the 61st through the 400th page of provided copies
  • $0.47 for any remaining pages of the provided copies

An additional charge will also apply for the actual cost of mailing, shipping, or otherwise delivering the provided copies.

If the requested records are provided on a digital or other electronic medium and the requesting party requests delivery in a digital or electronic medium, including electronic mail: (A) a retrieval or processing fee, which may not exceed $94.42 in addition to the actual cost of mailing, shipping, or otherwise delivering the provided copies.

In addition, the hospital or its agent 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 hospital may not charge a fee for: (1) providing health care information under subsection (b) to the extent the fee is prohibited under Health and Safety Code, Chapter 161, Subchapter M; (2) a patient to examine the patient's own health care information; (3) providing an itemized statement of billed services to a patient or third-party payer, except as provided under Health and Safety Code, §311.002(f); or (4) health care information relating to treatment or hospitalization for which workers' compensation benefits are being sought, except to the extent permitted under Labor Code, Chapter 408.

The statutes referenced in this notice may be found on the Internet at:

Should you have questions, you may contact the Health and Human Services Commission, Health Facility Licensing Unit, Mail Code 1868, P.O. Box 149347, Austin, Texas 78714-9347, (512) 834-6648, [email protected]. TRD-202104000 Karen Ray, Chief Counsel Texas Health and Human Services, Commission Filed: October 8, 2021.

Other Charges

USMD Hospital at Arlington may charge a reasonable fee for:

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

Download Forms

downloadPatient Release Authorization (English) downloadPatient Release Authorization (Spanish)
USMD Hospital at Arlington is a joint venture with Texas Health Resources and meets the definition under federal law of a physician-owned hospital. Doctors on the medical staff practice independently and are not employees or agents of the hospital. A list of physician owners is available upon request.