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Medical Records
Request Form
for Imaging Center Pickup

Medical Records Request Form for Imaging Center Pickup

 

* Required

  • MM slash DD slash YYYY
  • 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.

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

Masks Required

For the protection of patients and staff, ARA requires everyone who enters our imaging centers to wear a mask.

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