Release of Information (ROI) Request

To place a request for records, download and complete the Release of Information (ROI) form below. A valid request form must be completed in its entirety. Incomplete requests cannot be processed and will, therefore, be discarded. 

Requests are processed within 15 business days upon receipt. Fees may apply. Records are released in accordance with HIPAA as well as state and federal laws. 

Release of Information (ROI) Form


HOW TO REQUEST MEDICAL RECORDS:
  1. Download and complete the Release of Information (ROI) form. 
    1. Release To: A fax number and/or email address is required for the recipient.
    2. Information To Be Released: Initial next to each type of information that you request be released.
    3. Purpose For Release: Initial next to the reason you are requesting the release.
    4. Consent: Be sure to sign and date.
  2. Submit completed forms by:
    1. emailing records@dallasctc.com
    2. faxing 972-499-6935