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Patient Medical Records Request

Patient Medical Records Request

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  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • DISCLAIMER

    In agreeing to terms of use, I understand and accept full responsibility for the medical records (i.e., confidential information) I am about to receive. I relinquish Austin Radiological Association of any and all accountabilities concerning these medical records. I understand that I have the right, per HIPAA §164.508, to revoke this authorization in writing by sending written notice to: Attention: Privacy Officer, Austin Radiological Association, P.O. Box 4099, Austin, TX 78765. I understand that a revocation is not effective to the extent that Austin Radiological Association has relied on the authorization to disclose protected health information; and understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by law. THIS FORM IS NOT VALID 1 YEAR BEYOND DATE OF REQUEST. We are allowed to charge you a reasonable fee to cover our costs for making copies of digital images and may charge for multiple copies of paper records.

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You can request a copy of your Medical Records by completing an Authorization for Release of Medical Records. Because an actual signature is required to release medical records information, personnel at Austin Radiological Association are not allowed to process requests or authorizations received via email.

The following people are authorized to sign for release of your health information: The patient (Not the spouse) Power of attorney if the patient is unable to sign (Legal document must be provided.) Parent Parent and minor if the patient is 12 to 17 years of age and receiving psychiatric, alcohol, or drug treatment services Legal guardian (Proof of guardianship document must be provided.) Emancipated Minor (if the patient is 17 or 16 and provides a copy of the court order) Representative of the estate for deceased patients (Copy of the death certificate and a copy of the representative of estate documents must be provided.)

Copies are processed within 24 to 48 hours from the date the Authorization is received. Be advised that requests will not be complete until the Authorization for Release of Medical records form is received. Recipients will be notified if the request cannot be processed within the above time frame.

If you are a patient and have a question about your request for medical records, you may contact our Image Library department at (512) 719-8230; or you can send an email to [email protected].

There is no charge for releasing copies of health information directly to other health care providers. The patient will be responsible for any carrier fees except if mailed through regular US Mail.

Is It Time For Your Mammogram?

For quick, convenient service 24/7, self-schedule your appointment online. If you prefer, you may call (512) 453-6100

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