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Medical Records Request

How to Pick Up Medical Records

  1. Please report to the Outpatient Department, located on the Travis Street side of the facility.
  2. Bring a valid photo ID with you. Identification is required to release medical records.
  3. Outpatient staff will contact the Release of Information team to assist with your request.
  4. Records will be released in accordance with privacy and authorization requirements.
    For any questions or concerns, please call extension 143.

Medical Records Forms

English Versions

Request for Access to Protected Health Information
Authorization for Release of Patient Information

Spanish Versions

Solicitud de acceso a información de salud protegida
Autorización para la divulgación de información del paciente

Questions About Release of Information

At Liberty Dayton Regional Medical Center, we respect your privacy and your rights to access your health information. This FAQ is designed to make the process of requesting medical records simple and stress‑free.

Download FAQ Document
Hours of Operation

Monday–Thursday: 7:30 a.m. – 4:30 p.m.

Friday: 7:30 a.m. – 3:30 p.m.

We have two different forms, depending on what you need:

1. Request for Access to PHI (For Your Own Records)

Use this form when you want copies of your own medical records. You can request them for personal use, to share with another doctor, or just to review your health information. This is part of your rights under HIPAA.


2. Authorization to Release Health Information (Send to Someone Else)

Use this form when you want your records sent to another person or organization, such as:

• A family member
• An attorney
• An employer
• An insurance company
• A school

We can only send your records to someone else if you give written permission.

Quick Guide

• Access Request: “I want my own records.”
• Authorization: “Please send my records to someone else.”

If you’re unsure about which form you need, our Medical Records team is happy to help.

Please complete your form fully and accurately. Missing information may delay processing.

You can send your completed form in any of these ways:

• Fax: 936‑336‑7837
• Email: ROI@libertydaytonrmc.com
• Mail:
LDRMC – Release of Information
1353 N. Travis St.
Liberty, TX 77575
• In person: Outpatient Department (same address)

To keep your health information safe, we require a copy of your photo ID when you submit an Authorization form. This helps us:

1. Confirm Your Identity

We must be sure the request is coming from the patient or an authorized representative.

2. Protect Your Privacy

Your medical information is private, and your ID helps prevent it from being released to the wrong person.

3. Follow Privacy Laws

Healthcare organizations are legally required to protect patient information. Verifying your ID is part of that process.

  • Take a clear photo with your phone
  • Use a mobile scanning app
    • iPhone: Notes app
    • Android: Google Drive

Helpful Tips

  • Make sure the image is bright and not blurry.
  • Include the front (and back, if needed) of your ID.
  • Ensure the name on your ID matches the name on your form.

Most requests are completed within five (5) business days after we receive a complete and accurate form.

If we need additional information or clarification, the process may take a little longer.

You can contact the Medical Records department:

  • Phone: 936‑336‑7316 ext. 143
  • Email: ROI@libertydaytonrmc.com

Please allow 1–2 days after submitting your request before checking the status.

If you’re requesting records on behalf of someone else using a Medical Power of Attorney (MPOA):

Please provide:

  • A copy of the complete MPOA document
  • A valid government-issued photo ID
  • A completed Authorization for Release of Medical Records

Some MPOA documents have limits on what can be released, so it’s important the document includes permission to access medical records.

No. Liberty Dayton Regional Medical Center does not charge patients for copies of their health records.

If your doctor needs your records, the new provider can contact:

  • Health Information Management: 936‑336‑7316 ext. 143
  • Fax: 936‑336‑7837

We will fax the records directly to the provider.

Child Immunization Records
Visit the Texas Department of State Health Services website for information on obtaining immunization records.

Accounting of Disclosures
You may request an Accounting of Disclosures by fax, email, or mail.

Due to Senate Bill 922, your results may not appear in the patient portal until 72 hours after your date of service.

You may still register at any time.

If you need your results sooner, you can:

  • Pick up a copy in person, or
  • Ask us to send your results to your healthcare provider.