Medical Records
Request Form
for Imaging Center Pickup

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Medical Records Request Form for Imaging Center Pickup

"*" indicates required fields

I would like to pick up my report at*

First Name*

Middle Name*

Last Name*

Email*

Address*

Street Address City ZIP / Postal Code

Patient's Date of Birth*

Daytime Phone*

Mobile Phone

Date of Service*

Study Requested*

In what form do you need the Images/report?*

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.

Terms and Conditions*

I agree to terms of use

Additional Comments

This field is for validation purposes and should be left unchanged.

Medical RecordsRequest Formfor Imaging Center Pickup