We provide authorized access to patients' medical record information. We also provide general assistance in answering questions about medical record privacy.On the top Enter your information where the boxes ask for Patient Name, Date of. Birth, Social Security Number and Patient Address. You can fax a written request to 817-702-5700. A copy of our Authorization Form to release records is available on this page. How do I fill out a HIPAA release form? I, the undersigned, authorize the release of or request access to the information below from the medical record (s), of the above- named patient.