Instructions

In order to procure a copy of your medical record, you must complete BOTH steps below:

STEP 1: Complete, sign and submit form authorizing release of your record.

STEP 2: Submit required payment of $20.

*** THE VARIOUS OPTIONS FOR COMPLETING BOTH STEPS ARE LISTED BELOW: ……
OPTION #1:
Online
online
  • STEP 1:  Below this “Instruction” selection, choose the selection labeled “Fillable Online Request Form”.
  • STEP 2:  Follow the written directions.
  • STEP 3:  When form is completed and signed, click “SUBMIT”.
  • STEP 4:   NEXT: …. Submit the required fee.
    • a.  Proceed to the final selection choice, “Pay Online”.
    • b.  Fill in all required entries and submit the required fee of $20.
    • c.  Alternatively, mail a check/cashier’s check - made out to: Ronald D. Cates, MD.

** NOTE:  No records will be processed until BOTH the FEE of $20 and the REQUIRED FORM have been received.

OPTION #2:
By Email
email
  • STEP 1:  Below this “Instruction” selection, choose the selection labeled “Mail Instructions”.
  • STEP 2:  Follow the written directions.
  • STEP 3:  Download/Print the form by choosing the 3rd selection labeled “Printable Form”.
  • STEP 4:  When form is completed and signed, send by MAIL following the provided instructions.
  • STEP :5   NEXT: …. Submit the required fee.
    • a.  Mail a check/cashier’s check for $20 - made out to: Ronald D. Cates, MD.
    • b.  Alternatively, proceed to the final selection choice, “Pay Online” and complete the very simple credit card payment for $20.

** NOTE:  No records will be processed until BOTH the FEE of $20 and the REQUIRED FORM have been received.

OPTION #3:
By Fax
fax
  • STEP 1:  Below this “Instruction” selection, choose the selection labeled “Fillable Online Request Form”.
  • STEP 2:  Follow the written directions.
  • STEP 3:  Download/Print the form by choosing the 3rd selection labeled “Printable Form”.
  • STEP 4:  When form is completed and signed, send by FAX to 903-677-4858.
  • STEP 5:   NEXT: …. Submit the required fee.
    • a.  Proceed to the final selection choice, “Pay Online”.
    • b.  Alternatively, proceed to the final selection choice, “Pay Online” and complete the very simple credit card payment for $20.

** NOTE:  No records will be processed until BOTH the FEE of $20 and the REQUIRED FORM have been received.

** You may call “Medical Records Custodian” at 903-677-4858 and leave a recorded message to address any other questions.

Mail Instructions

Want to submit your paperwork through the mail?

Download the form below and mail completed/signed form along with payment in full to:

Medical Records Custodian
Post Office Box 164
Athens, TX 75751

Medical Records Processing is $20 USD. We accept personal checks and cashier's checks made payable to: Ronald D. Cates, MD

Printable Form

Fillable Online Request Form

PLEASE NOTE: If not submitted by selecting the “SUBMIT” button BEFORE closing this page, this form WILL NOT BE SAVED. All information recorded, if not submitted by selecting the “SUBMIT” button, will be deleted when this page is closed. Before beginning, have available all of your information required to complete this form in total and during the same sitting.

Fillable Online Request Form

Pay Online