321 S. Henderson St., Fort Worth, Texas 76104, United States
hXe's online authorization will be securely transmitted to the healthcare provider's staff to process. You will be able to track the progress of your request in your account. Once records are ready, you will receive a download notification to log in and download your records. Time to fulfill medical record requests vary by healthcare providers depending on scope of information needed and internal turnaround times. If you have any questions about obtaining your records, please contact the healthcare provider directly.
Please select from the below:
Upload Valid Government Issued Photo ID (optional but recommended)
I understand that once the Covered Entity (Medical Provider) discloses my health information to the recipient, the Covered Entity and its affiliates cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable law governing the use and disclosure of my health information.
I understand that I may at any time make a written request to the Covered Entity and its affiliates to inspect and/or obtain a copy of my health information, and that the Covered Entity and its affiliates will either, within five days for a request to inspect and fifteen days for a request to copy, grant the request and contact me to arrange for a convenient time to inspect and/or copy my health information or provide me with a written denial of the request that states the basis for the denial, my review rights (if any), and instructions as to how and to whom I may register a complaint regarding the denial.
I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment; except, however, if my treatment is for the sole purpose of creating health information for disclosure to the recipient identified in this Authorization, in which case the Covered Entity and its affiliates may refuse to treat me if I do not sign this Authorization.
I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to the Covered Entity’s Privacy Office. The revocation will be effective immediately upon the Covered Entity's receipt of my written notice, except that the revocation will not have any effect on any action taken by the Covered Entity in reliance on this Authorization before it received my written notice of revocation.
I have read and understand the terms of this Authorization. By my signature below, I hereby, knowingly and voluntarily, authorize the Covered Entity to use or disclose my health information in the manner described above.
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