League City Family Clinic

Medical Records Request Form

In order to adhere with HIPAA requirements, medical records must be picked up by, mailed to, or emailed to the patient listed below or his/her guardian.

Patient Full Name *

Patient Email

Patient Phone Number *

Date of Birth *

Patient Mailing Address *

Your records will be mailed to this address.

Type of Record Requested *

Paper Copy for Pick Up

Mailed Paper Copy

Email (by checking this box, you consent to receiving your medical records via email)

Patient Signature *