PARKLAND HEALTH & HOSPITAL SYSTEM - Dallas, Texas 2026

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  1. Click ‘Get Form’ to open the PARKLAND HEALTH & HOSPITAL SYSTEM authorization form in the editor.
  2. Begin by filling out the 'Patient Information' section. Enter the patient's name, MRN number, address, date of birth, and contact details accurately.
  3. In the 'Receiving Facility / Individual Information' section, specify who will receive the medical information by providing their name, telephone number, and address.
  4. Select the purpose of your request from the provided options such as legal, personal use, or continuity of patient care.
  5. Choose your preferred format for receiving records (e.g., CD, paper) and indicate your delivery method (fax, mail).
  6. Check all applicable general medical records and imaging/radiology records you wish to request.
  7. Finally, ensure that you sign and date the form at the bottom. If applicable, include interpreter details.

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