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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

Patient Requests

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

Physician requests

We process physician requests for:

  • Reports, images, comparison reads or questions regarding reports
  • Lab results
  • CDs of images
  • Importing images from outside CDs for comparison reads
  • Film reprinting for all studies
  • Updating physician profiles
  • Adding physicians to our systems

For all Memorial Hermann Imaging Center customer service needs, call (713) 778-2545, Monday – Friday 8 a.m. – 5 p.m.

Authorization to Release Patient Information

You may request your test images and records by phone or fax. Please be prepared to give patient name, date of birth, type of study, physician name and address and date / time needed.

Phone: (713) 778-2545 (option 1 for physicians)
Fax: (713) 778-2577

Clinical Forms

To help expedite your visit, you can print and complete your clinical forms ahead of time. Please be sure to bring all completed forms with you to your appointment, along with:

  • Doctor’s order for the exam
  • Medical insurance card(s)
  • Driver’s license or other identification card
  • Form of payment (we accept credit cards)
  • Completed clinical forms

Please note: Additional forms, including consent forms, may need to be completed upon arrival.