Patients needing their medical records from TOPS Comprehensive Breast Center may request them four ways:

1. By Mail

Download this form, fill it in and send it by mail to:

TOPS Comprehensive Breast Center

Attention: HIM Department

17030 Red Oak Drive

Houston, Texas 77090

2. By E-Fax #: 281-754-4220

Download this form, fill it in and fax it to the number above.

3. By email:

Download this form, fill it in, scan it as an image (.pdf, .jpg) and attach it to an email to the above address.

4. By online form:

Simply fill out the form below and someone will be in touch with you shortly.

Patient Name:*
Complete Address:*
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I, (type your full name)*
hereby authorize TOPS Comprehensive Breast Center to use or disclose the following protected health information:
The protected health information may be disclosed to: (Please provide the name of the person(s) or entities to whom the protected health may be disclosed. If the records are to be mailed please provide the name and address where to be mailed.)
Release of medical records to be:*
The protected health information is being used or disclosed for the following purposes: (If the disclosure is at the patient’s request and the not choose to provide an explanation, the patient may indicate “At the patient’s request.” Otherwise, please provide the specific purpose(disclosure.) disclosure.)
This authorization will become invalid 180 days from the date of signature unless revoked earlier. A copy or facsimile of this authorization is the original.
I understand that, as set forth in the Provider’s Privacy Notice, I have the right to revoke this authorization at any time by sending written notice to:
TOPS Surgical Specialty Hospital
17080 Red Oak Dr.
Houston, TX 77090
Attn: Privacy Officer
I understand that a revocation is not effective to the extent that the Provider has taken action or relied on the authorization that is being revoked.
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may not be protected by federal or state law.
I understand that (Check one of the following):
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This field is for validation purposes and should be left unchanged.