Patient Forms & Medical Records
Medical Release Forms
To Tepeyac OB/GYN: Use this form to send your medical records to Tepeyac OB/GYN from another practice. (This form is for Tepeyac patients only.)
Current Patients with Tepeyac OB/GYN: Requests for copies of your medical records must be in writing, signed by you or your personal representative (that is, someone authorized by law to exercise rights on your behalf such as a parent of an unemancipated minor, the executor of an estate, a legal guardian, or anyone else empowered through a power of attorney or legal process to make health care decisions on your behalf) that clearly identifies to whom and where to send copies of the records and by what method. Records may be sent by mail, email, secure fax, or other agreed upon method. Copies may be picked up at Tepeyac’s office by you, your personal representative, or a person designated by you or your personal representative.
Use this form to release your medical records from Tepeyac directly to another practice or other third party. If you request an unsecure method of transmission, the security of your information is at risk.
Use this form to release your medical records from Tepeyac to you.
Use this form to designate a person to pick up your medical records at Tepeyac’s offices. Photo ID and a copy of the form must be presented at pickup.
Patient Forms
Please select the appropriate form below.
New Patient Forms
En Español
- Paquete para Pacientes Embarazadas
- Paquete de Ginecología
Medical Records
Sending records to Tepeyac:
Complete the Authorization to Release Records to Tepeyac.
Requesting records from Tepeyac:
Complete the appropriate Medical Records Release Form.
Please allow 7–10 business days for medical records requests. Requests must be submitted in writing; we cannot accept medical records requests by phone.
Forms, Letters & Disability Paperwork
- Disability forms: $45
- Custom letters or administrative forms: $45
- 24-hour rush requests: additional $20
Payment is required before processing. Please allow 5–10 business days for standard requests.
Notice of Privacy Practices
Please review our current: