Request for Access to Health Information

Connxus maintains health information as part of its role as a Health Information Exchange (HIE). You may use this form to request access to health information maintained by Connxus.

Please complete all required fields. Incomplete requests may delay processing.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Date of Birth *

Street Address *

City, State, Zip Code *

Phone Number *

Email *

Name of Requester

If not the patient

Relationship to Patient *--- Select Choice ---SelfParentLegal GuardianPersonal RepresentativeOther

understand of Description

Type of Information Request *--- Select Choice ---Clinical (e.g., Visits, Diagnosis, Medications, etc.)Social Needs/SDOH Assessment and ReferralsOther

Information Request Description

If you selected Other, please specify here.

Date Range of Request *

From Start Date - End Date

Delivery Method *--- Select Choice ---Secure EmailMail (Paper Copy)

By submitting this request, I understand that: *

• Connxus operates as a Health Information Exchange and maintains health information received from participating providers and partners.
• Connxus will provide access to health information maintained within its systems.
• Connxus may not maintain a complete medical record. Additional records may be available directly from healthcare providers. A list of participating providers is available on the Connxus website.
• My request will be processed in accordance with applicable law, including the Health Insurance Portability and Accountability Act (HIPAA) and Texas Health & Safety Code Chapter 181.
• Connxus will make reasonable efforts to provide the requested information within 15 business days of receiving a complete request.
• Connxus may verify my identity prior to releasing health information and may deny or limit requests as permitted by law.

Electronic Signature *

Please type out your name and today's date to be used as an electronic signature.

Submit