Please choose one of the options below to submit a medical record, imaging or billing record request.
Online requests are managed through Verisma. Submit your request here:
Please download the Authorization for Release of Patient (Opens in new window) Information form. Complete all required fields, sign, date, and return the form using one of the methods below:
WellMed
Health Information Management Department
909 Hidden Ridge Drive
Suite 300
Irving, TX 75038
817-514-7879
Attn: Health Information
Management Department
*If you choose to return the completed form via an encrypted email, please note email is not a secure method of communication and carries some risk of being read by a third party.
Download Authorization for Release form (Opens in new window)
Online requests submitted through Verisma:
Requests sent via mail, fax or email:
No
Please have the doctor or clinic fax their request to 1-817-514-7879 Records will be sent directly to them.