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200 Westpark Way, Euless, TX 76040

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Medical Records Request

Mid Cities Psychiatry
Medical Records Request

Make A Request!

Please Choose Below The Request Type

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Is Medical Records Request for self or to allow others to receive your medical and mental health information?*
- MCP is Sending MRs
- MCP is Receiving MRs
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To Seema Kazi, MD dba Mid Cities Psychiatry

This is an authorization of your medical information to be transferred between health care providers, health insurance companies and any other party involved in your medical care.
Patient's Last Name*
Date Of Birth*
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Phone #*
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Age*
We apologize for the inconvenience and we only see patients 16 years of age or older.
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I hereby authorize the following facilities/hospitals and doctor(s) to release all medical information to Seema Kazi, MD dba Mid Cities Psychiatry for treatment consultation and to better manage my health.

This request includes hospital summaries, echocardiogram reports, cardiac catheterization reports, laboratory reports, electrocardiograms, physician progress notes, labs, and any other healthcare information relating to my condition including my mental health progress notes.
I understand and agree that I have the right to revoke this authorization anytime by sending/giving a written notice to Mid Cities Psychiatry And until I revoke this authorization in writing, this authorization is valid indefinitely.*
- Yes
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Do you want Additional Person/Medical Entity to release your information pertaining to your medical care including mental health?*
- Yes
- No
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Name*
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Do you want Additional Person/Medical Entity to release your information pertaining to your medical care including mental health?*
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- No
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Do you want Additional Person/Medical Entity to release your information pertaining to your medical care including mental health?*
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- The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records. The release also allows the added option for healthcare providers to share information. A medical release form can be revoked or reassigned at any time by the patient when a request is received to the clinic from the patient in writing.
- The provider reserves the right to deny a self-medical records request and the provider must approve the request before the records may be released.
- There’s no charge if the Medical Records are to be sent electronically to another Medical Entity. However, if the Medical Records are to be mailed to another Medical Entity, there will be a postage charge.
- For Medical Records in Paper Format, there’s a $25.00 charge for the first 20 pages and $0.50 per page for each additional page plus postage (if to be mailed)
- For Medical Records in Electronic Format, there’s a $25.00 charge for the first 500 pages and $50.00 for more than 500 pages.
- There is a $15.00 charge for affidavit requests.
- Please allow 5 business days to process the request.
- You can submit the request using the form provided below or by faxing the request to 855-295-2686
- For questions/concerns about the Medical Records Request, please send an e-mail at MRs@MidCitiesPsychiatry.com or call 817-488-8998 ext 7
- Please know before fulfilling your medical record request, we’re required to have your “Authorization to Release Healthcare Information” signed by you.
I Agree*
- I Agree
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Patient's Last Name*
Date Of Birth*
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Age*
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We apologize for the inconvenience and we only see patients 16 years of age or older.
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Do you have a new phone #?*
- Yes
- No
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New Phone #*
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Same Phone #*
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Do you have a new email?*
- Yes
- No
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Zip/Postal Code*
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Have you moved?*
- Yes
- No
New Address
Street Address*
City*
State*
State
Zip/Postal Code*
Please upload your Driver's License
Please provide the front image of your Driver's License in PDF format*
Accepted file types: pdf, Max. file size: 120 MB.
Please provide the back image of your Driver's License in PDF format*
Accepted file types: pdf, Max. file size: 120 MB.
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Reason for Medical Records Request*
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Reason*
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Facility's Name*
Facility's Provider's Name*
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Relationship*
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Have you signed the “Authorization to Release Healthcare Information”?*
- Yes
- No
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To Seema Kazi, MD dba Mid Cities Psychiatry

Authorization to Release All Healthcare Information Including Mental Health To Other Person(s) and/or Medical Entity/Entities
I hereby authorize the following person(s) to be involved with and receive information pertaining to my medical care including mental health.

I understand that any and all information can only be given in person, and after presenting a picture ID.
I understand and agree that I have the right to revoke this authorization at any time by sending/giving a written notice to Mid Cities Psychiatry. And until I revoke this authorization in writing, this authorization is valid indefinitely.*
- I agree
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Do you want Additional Person/Medical Entity to be involved with and receive information pertaining to your medical care including mental health?*
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- No
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- No
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Contact Us!

200 Westpark Way, Euless, TX 76040

(817) 488-8998

(855) 295-2686

Monday – Friday, 8 am-5 pm

1323 E Franklin Street, #102 Hillsboro, TX 76645

(254) 266-6262

(855) 295-2686

Monday – Friday, 8 am-5 pm

About The Mid Cities Psychiatry

Mid Cities Psychiatry specializes in the diagnosis, treatment and mental health issues, including substance use disorders. We are qualified to assess both the mental and physical aspects of psychological disturbance.

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