14100 SAN PEDRO AVENUE, SUITE 608, SAN ANTONIO, TEXAS PHONE: (210) 543-7334 FAX: (210) 263-9998
Patient Authorization for Release of Health Records
1. I authorize _______________________________________________to disclose information from the health records of:
_______________________________________ Account #: _______________ Date of Birth: _________________
(patient full name)
2. The information is to be disclosed to: ____________________________________________________________________
Address (sender/receiver if other than Little Spurs Pediatric Urgent Care):_________________________________________
City, State, Zip: _______________________________________________________________________________________
Contact Person: _____________________________________Phone:_______________________/Fax:_________________
E-mail Address: __________________________________________________________________ _____________
_______
I authorize this information to be disclosed in the following ways:
q Written/Photocopy/Paper
q Verbal
q Fax
q Electronic Mail *
Purpose of the disclosure: ______________________________________________________________________________
3. Dates of Treatment: From: _____________________________________ To: ____________________________
Specific reports to be disclosed:
q Progress Notes
q Discharge Summary
q X-ray films or other images
q Laboratory Reports
q Radiology Reports
q Photographs/Videotapes
q Operative Reports
q Consultation Reports
q Records from other facilities
q Entire Health Records (including, but not limited to, information regarding medical/health treatment, insurance,
demographics, referral documents, and records from other facilities.)
q Other(Specify):______________________________________________________________________________
I give specific authorization to disclose the following information:
I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no
longer be used or released for the reasons covered by this authorization. However, any disclosures already made with my
permission are unable to be taken back. I may revoke this authorization by notifying Little Spurs Pediatric Urgent Care in
writing.
My treatment will not be based on the completion of this authorization form. The information to be released by this
authorization may be re-released by the person or organization that receives it and may no longer be protected by Federal or
Texas privacy regulations.
Information disclosed pursuant to the authorization may be subject to re-disclosure and may no longer be protected by the
Privacy Rule.
Unless revoked earlier, this authorization expires in one year unless I specify another time: __________________________
I release the individual or organization named in this authorization from legal responsibility or liability for the disclosure of the
records as authorized on this form. I understand that this authorization is voluntary and that I may refuse to sign it. I will be
provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original.
_______________________________________________ _____________________________________________
Signature of Patient (or Patient Representative) Date
_______________________________________________ _____________________________________________
Printed Name of Patient or Patient Representative Authority of Representative to Act for Patient
(Relationship to Patient)
Note: Need to ensure separate E-mail Authorization Agreement is signed.
Note: Release of Psychotherapy notes requires a separate authorization.
Records Release 20160121_2017040_20180713_20180906
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
REQUESTOR
CHARGE
PHYSICIANS, HOSPITALS, AND TPO
NO CHARGE TO FAX
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
AFFIDAVIT: EACH
$15.00 PER FORM
NOTARY
$6.00 PER SIGNATURE
POSTAGE RESTRICTED RETURN RECEIPT
$25.00
CD - COPY OF X-RAY
$8.00 PER COPY
SOCIAL SECURITY BENEFITS
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.