Medical Records
Request Form
for Imaging Center Pickup

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* Required

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*
MM slash DD slash YYYY
Daytime Phone*
Mobile Phone
Date of Service*
MM slash DD slash YYYY
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
Name
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Medical RecordsRequest Formfor Imaging Center Pickup