Patient Forms

Please note that there will be a delay for patients trying to retrieve medical records from Clary Document Management Do to technical difficulties retrieving records from the ECW EMR team at Memorial Hermann, this issue will be corrected shortly and records may be requested after January 1st. 2022.  Thank you for your patience. 

Patient release of records form and information.

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)