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Need us to have your complete history? Use this form to request that another healthcare provider or facility send your medical records directly to PrimeCare Emergency Center.

I authorize PrimCare to disclose the above name individual’s private health information.
This information may be disclosed TO and used by the following individual or organization:

I understand that the information in my health record may include information related to sexually transmitted disease, acquired immunodeficency syndrome (AIDS), or human immunodeficency virus (HIV). It may include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

If no expiration is selected, the authorization will automatically expire 180 days from the date of signature, as permitted by Texas law.

I have the right to revoke this authorization at any time by submitting a written notice to PCEC.

If I revoke, PCEC will stop using or disclosing my PHI after the revocation date, except for actions already taken in reliance on this authorization.

I understand that once my health information is disclosed to the recipient listed above under this authorization, that recipient may redisclose my information, and that it may no longer be protected by federal or Texas privacy laws.
If I revoke, PCEC will stop using or disclosing my PHI after the revocation date, except for actions already taken in reliance on this authorization.

Fee charged for reproduction of records:
$25 (pages 1-20),
$0.15 per page thereafter

Cost of Affidavits/Notary (If needed):
$15 per signed page

Request Another Provider to Send Records to PrimeCare

Authorize PrimeCare Emergency Center to send your medical records to you, a family member, another healthcare provider, or an insurance company.

I hereby authorize the release of information concerning my treatment from:

You have the right to revoke this authorization at any time by submitting a written revocation to PrimeCare Emergency Center’s Medical Records Department. Revocation does not apply to information already released in response to this authorization.

Request PrimeCare to Release Your Records

<p>It’s important to know where your nearest emergency center is in the most unexpected of times, that's why the staff at PrimeCare Emergency Center offers services to their patients 24-hours a day, 7 days a week!</p>

Emergency Center in Arlington

You Don't Have to Come Into the Office for a Fresh Start

<p>For emergencies, please call us at (682) 323-8899 or call 911. By submitting, you agree to receive text messages from PrimeCare Emergency Center at the number provided, including those related to your inquiry, follow-ups, and review requests, via automated technology. </p>

24/7 Emergency Care in Arlington: We're ready whenever you need us

You Don't Have to Come Into the Office for a Fresh Start

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