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Release of Information

Choose an Option Below to Obtain a Copy of Your Medical Records

Option 1: Request your Medical Records Online (Adobe Sign Documents) to be transferred to Kelsey-Seybold Clinic

For English Use This Form
For Spanish Use This Form

This form will automatically send your request to Kelsey-Seybold Clinic for processing.

Option 2: Request your Medical Records to be transferred from Kelsey-Seybold Clinic using a printable PDF. 

For English Use This Form
For Spanish Use This Form

When you complete and sign the form, you authorize the release of your medical records to a healthcare provider of your choice. You may return the completed form to our Medical Record Department or Radiology Department for processing in two ways:

Medical Record Department:

  1. By faxing to 713-442-2804.
  2. By mail to:
    Kelsey-Seybold Clinic - Meyerland Plaza
    Attn: Release of Information Department
    560 Meyerland Plaza Mall
    Houston, TX 77096

Radiology Department:

  1. By faxing to 713-442-1175.
  2. By mail to:
    Kelsey-Seybold Clinic – Radiology Department
    2727 West Holcombe Blvd.
    Houston, TX 77025

For assistance with your request, you may contact the departments below:

Medical Record Department: 713-442-5700– M-F 8:00 am – 5:00 pm

Radiology Department: 713-442-1168– M-F 8:00 am – 5:00 pm

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