Medical Records

Print or download the Release of Medical Information Authorization Form and complete the form according to the instructions given below. Bring the signed authorization, along with a form of personal identification, to the SCH Medical Records Department or mail them to:

Sweeny Community Hospital,
Medical Records Department
206 N. McKinney St
Sweeny, TX 77480

Faxed authorizations will not be accepted.

Insert the name of the health-care facility you want to get a copy of your records from, (i.e., Sweeny Community Hospital).

Insert the address of the facility (not necessary if for Sweeny Community Hospital).

Put a check in the box beside the parts of the medical record you want. There will be a charge if the number of pages is more than 10. If you are not sure which parts of the record you need, please call us.

Insert the name and address of the person or facility to receive the copy of your medical record. If it is yourself, put in your information.

State the reason you need a copy of your record, (for example: continued care, file insurance claim, personal use, legal purposes).

Insert the patient’s identifying information and the date(s) of treatment.

If you are 18 or older and the request is for your own records, sign your name.

Insert the date the form is signed.

If the patient is under 18, a parent or guardian must sign the form, list the relationship to the patient and state the reason the patient cannot sign the form. Example: The patient is 10 years old and lives with his/her parents. One of the parents would sign the form, list “parent” as the relationship and state “minor child” as the reason the patient is unable to sign.

If the patient is an adult (18 or older), only the patient may sign the authorization. Neither spouses nor adult children may sign the authorization unless the patient has named them as their designated agent in a medical power of attorney.

If the patient is a minor (under age 18, unless emancipated), parents may sign. If the parents are divorced, the divorce decree will be reviewed to see who is authorized to release medical information.

If the patient has a legal guardian, guardianship papers may need to be reviewed.

Exceptions: Minors who seek treatment for pregnancy or sexually transmitted diseases must authorize the release of information themselves.

Ten pages are provided free. After that, the fee is 50 cents per page, which must be paid before the copies are released.