Patient Forms

If you would like to have a release of records form for you records please download and fax a signed release of records to (888)809-8549

Request For Release Of Records.

Download
New Request For Release of Records.pdf
Adobe Acrobat document [273.2 KB]
Download
Clary “Authorization to release Medical Record” form
Clary Document Management is the custodian of your records for Rios Family Medicine Clinic effective October 15, 2021. Your medical records are confidential, a copy of your medical records can be made and sent only with your written permission. If you or your new physician needs a copy of your medical records, please download This form. This record retrieval service will be available for seven years beginning on October 15, 2021, and ending on October 14, 2028. Any fee for your records will be assessed in accordance with Texas Health and Safety Code 241.154.
Clary “Authorization to release Medical [...]
Adobe Acrobat document [2.2 MB]

Important telephone numbers for in case of emergencies:

Organization Telephone Number
Emergency Services & Fire Department 911
Centers for Disease Control and Prevention 800-CDC-INFO (800-232-4636)