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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.

Scheduling Notice

ARA is experiencing record call volumes. We are aggressively working to remedy this situation. PLEASE NOTE THAT SCREENING MAMMOGRAMS AND ULTRASOUNDS CAN BE SCHEDULED ONLINE. If you schedule a callback and your call is not received during the predicted time frame, please note you are still in the queue and we will call you back as soon as an agent is assigned to your call. We apologize for the extra wait time you may experience and appreciate your patience. For routine X-ray, scheduling is not required--you can walk into any ARA location that does X-ray.

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