Each field on the form must be completed. Be certain to submit a complete address and telephone number for the person to whom the information should be released. Check the appropriate boxes for the items that you would like copied. If the item needed or purpose for the release is not listed, please write it on the line marked “other.” Initial the box where appropriate. Sign and date the bottom of the authorization.

Please note there is a fee for copying records.  

Send the original to the Records Management Department, DePelchin Children’s Center, 4950 Memorial Drive, Houston, TX  77007.

A Records Management Technician will contact you regarding applicable fees and to make arrangements for the method of disclosure.  

If you have further questions, please feel free to contact the Records Management Department at 713-802-3858 or info@depelchin.org.

Please allow 14 days to process the request.