Release of Medical Records

If you would like to transfer your medical records to Kelsey-Seybold Clinic, use this form.

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

If you would like to request your medical records to be transferred from Kelsey-Seybold Clinic, 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 Records Department for processing in two ways:

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.

You can call our Medical Records Department at 713-442-5700 for assistance with your records request.