Medical Release

South Austin Medical Clinic, P.A. AUTHORIZATION FOR RELEASE OF INFORMATION

2555 Western Trails Blvd., Ste. 101; Austin, TX 78745 Phone: 512 892 6600 Fax: 512 892 6609

I, the undersigned, do hereby request and authorize South Austin Medical Clinic to release or obtain information described below from the medical records of:

Patient Name*

Date of Birth*

Date

Social Security Number

Current Phone #*

Address/City/State/Zip Code:*

***PLEASE INCLUDE COMPLETE ADDRESS ON ALL ADDRESS FIELDS TO AVOID DELAYS IN PROCESSING***

Select One:*

	Select One
Release records to South Austin Medical Clinic
Obtain records from South Austin Medical Clinic

Select One:*

	Select One	Name and address
Release records to
Obtain records from

All records requested by patient will be given on a CD or transferred by fax to new primary physician. The fee cost for the release of medical records is $6.50. If records are to be printed the fee is $6.50 for the first 20 pages and $.50 per page thereafter.

Select One:

	Select One	Initial
ALL RECORDS will be sent EXCEPT those initialed
Alcohol/drug related (including rehabilitation programs)
Mental Health (including psychology, psychiatry)
Sexually Transmitted diseases(to include HIV)
History & Physical
Consultations
Laboratory
EKG
X-Ray
Progress Notes

Or

	Select One	Specify which records are needed
Specific dates of treatment/ Illness/Injury/Accident

Article 4495b; Section 5.08(j) Texas Revised Civil Statutes requires that an authorization for release Of records include “the reason or purpose for the release”

I am transferring my complete medical record terminating my patient status from the releasing physician(s). Reason

The Texas State Board of Medical Examiners approves an initial fee of $25.00 for the *first 20 pages of a record and $.50 per page thereafter. These fees apply if an attorney, insurance carrier or third party on you behalf request copies. Fifteen days should be allowed for our office to provide these records after a signed authorization and payment has been received. The fee cost for the release of medical records directly to a patient is $6.50.

I understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it. I understand that in any event this authorization expires automatically in ninety days fro the date of this signature.

The fee is waived if the records are used to support an application for disability or benefits under: AFDC, Medicare, Medicaid, Social Security Administration or Federal Old age Survivors Insurance. I have attached a statement which confirms that an application or appeal has been filed or in pending.

The patient agrees that a photocopy, CD or fax copy authorization and records may be considered valid.

Signature*

Clear

Date*

Date

Representative or personal legally authorized to sign.

Clear

Relationship to Patient

Please DO NOT fax records if more than 10 pages