Request Imaging Records

Request Imaging Records, including Films and CDs

To request a copy of your medical records, including test images (film or CD), download, print, complete and sign the applicable form below. Fax the completed form to Memorial Hermann at (713) 778-2577, attention: Request for Protected Health Information.

Record Release Forms

• Request for Protected Health Information - For Requests External to Memorial Hermann - English
• Request for Protected Health Information - For Requests External to Memorial Hermann - Español
• Request for Protected Health Information - For Requests Within Memorial Hermann - English
• Request for Protected Health Information - For Requests Within Memorial Hermann - Español

We process patient requests for:

• Test reports
• Images (films or CDs)
• Film reprinting for all studies
• Importing images from outside CDs for comparison reads
• Business Office questions
• Scheduling
• Insurance verification