14100 SAN PEDRO AVENUE, SUITE 608, SAN ANTONIO, TEXAS PHONE: (210) 543-7334 FAX: (210) 263-9998
Request for Protected Health Information (Medical Records)
Little Spurs Pediatric Urgent Care accepts requests for Protected Health Information (medical records). In
order to process requests for medical records quickly and accurately, these guidelines are provided for
your convenience. Please read carefully. Keep this for future reference.
Requests for Protected Health Information, or Medical Records, are processed in accordance with federal
HIPAA and Texas State HB300 privacy laws. Please follow the steps listed below:
1. Complete, sign and date an "Patient Authorization for Release of Health Records”. Be sure to complete ALL blank
lines on the form. Please include a phone number where you can be reached. We will call you if we have
questions and when the records are ready.
2. List the date(s) of service for which you are requesting. You may indicate all dates.
3. Check or specify exactly what information you need from the medical record.
4. There is a charge for medical records, payable in advance.
5. The more specific the information you provide regarding your information needs, the lower the
charges will be for copying. For example: If you need notes for one visit date, do not request the
entire medical record. You may request a summary of any or all the visit notes.
6. The law allows the records to be processed 15 days after the date of our receipt of the request. Normal
processing time is much quicker.
7. In a few cases, a request is denied due to specific reasons or errors. Common errors include: An incomplete
Authorization form (ALL blank lines must be completed), an unauthorized representative is requesting records,
etc. We will contact you if your request is denied.
8. Once the request for medical records is processed and complete, the Company representative will contact you
to discuss any fees, the method of payment and instructions for pick up. For an additional mailing fee, records
can also be mailed.
9. The fee schedule is listed below. Fees are set by the Texas Administrative Code, Chapter 165, Title 22, Part
9. A provider’s office is not required to permit copying until the fee is paid.
MEDICAL RECORDS COPY FEES
PHYSICIANS, HOSPITALS, AND TPO
ALL OTHER REQUESTORS: PATIENTS, ATTORNEYS, OTHER ENTITIES
FMLA FORMS:
1-20 PGS. $6.50
$0.50 CENTS PER PAGE FOR EVERY COPY THEREAFTER
USPS MAIL FEES APPLY FOR MAILING RECORDS
$25.00 Per Form
POSTAGE RESTRICTED RETURN RECEIPT
NO CHARGE IF WRITTEN PROOF IS PROVIDED FROM SOCIAL SECURITY
ADMIN.
10. The Medical Records department representative can be reached Monday through Friday 9 AM to 4 PM. Please
call 210-543-7334 and listen for the Medical Records prompt, or dial 0.
11. If no one answers, please leave a detailed message and we will return your call.
12. MEDICAL RECORDS MAY BE PICKED UP AT ANY LOCATION, INCLUDING THE CLINIC WHERE YOUR CHILD WAS
SEEN. PICK UP HOURS ARE: MONDAY THRU FRIDAY 9AM-4PM. Please take this informational paper with you
for future reference.
A VALID GOVERNMENT PICTURE I.D. IS REQUIRED TO VERIFY YOUR IDENTITY UPON RECORDS PICK UP.