Release of Information Authorization Form

ROI Authorization Form

Please complete the attached form in order to request a copy of your medical records. The form may be hand delivered or mailed to Park Plaza Hospital

Attn: Medical Records Dept.
1313 Hermann Drive
Houston, TX 77004

Please include a copy of an official photo ID (ex. drivers license, passport, ect.) There will be a flat $25 fee to receive an abstract of your records. If you would like to receive your complete record, please contact the Release of Information Representative at 713-527-5010 for the total cost.