Medical Records Request

Print
Press Enter to show all options, press Tab go to next option

Please read the Fort Bend County EMS Notice of Privacy Practices

Fort Bend County EMS will provide copies of a patient's medical run record, as required by law, utilizing the following procedure:

  1. The Authorization for Disclosure, Use or Receipt of Protected Health Information Form [PDF] must be submitted, in writing, to the Medical Records Clerk, via fax, e-mail, or U.S.P.S.  The request should provide as much information as possible about the incident:  patient's full name, date of birth, date(s) of service, and, if possible, time of day service was provided, location of incident, type of incident, and any other information which will aid in locating the document or documents requested.  Completed form must be signed by the patient or personal representative and accompany the written request.  Please include your contact information, including e-mail address, in your written request.

Once the request and proper authorization form is received, you will be invoiced for your records. You must submit payment and a self-addressed stamped envelope to the Medical Records Clerk when sending your written request. Your records will be mailed to you in the envelope you provide as soon as payment is received.

The fee for copies of medical records is 20 cents per page.  Affidavits provided by the requestor will be completed and notarized for an additional fee of $20.00.

View the Privacy Policy concerning Protected Health Information (P.H.I.) for more information or to request medical records contact the Administrative Assistant at 281-633-7086.

Free viewers are required for some of the attached documents.
They can be downloaded by clicking on the icons below.

Acrobat Reader Flash Player QuickTime Windows Media Player Microsoft Silverlight Word Viewer Excel Viewer PowerPoint Viewer