This HIPAA Release Form Sends your Medical Records Away from Our Office

Because your teen's medical records are confidential, this HIPAA Release Form is needed to forward records to any place outside my office.  (There are certain exceptions provided in the HIPAA Privacy Guidelines.)

Good News!  If all you need forwarded is an Immunization Record, parents / legal guardians or patients over 18 can simply call the office.  Give us phone permission to print it for your personal records or forward it anywhere you wish.  We will do that for FREE.

HIPAA Release Form Costs

The Texas State Medical Board allow physicians to charge for records in certain conditions.  If you complete the release and ask records to be forwarded to another healthcare provider, there is no charge.

Under certain conditions, we may charge for records if they are sent to any entity other than a healthcare entity.

If you wish to have complete or partial records printed for your own use or to be 'picked up by the patient / parent / legal guardian' , the following charges will apply.  Charges will be paid before the records are released.

Immunization Record only:

  • FREE

Paper Records

  • First 20 pages:  $25
  • Every page after 20: 50 cents per page

CD Disk

  • $25 per disk regardless of amount of information on the disk

Billing Records

  • $25 for the complete or partial billing history

Signed Affadavit / Doctor Signature Required Form for Release

  • $15 per form

Additional costs added to any of the above if used:

  • Postage if mailed.
  • Cost of Supplies used.
  • Actual Labor / Personal Delivery costs, billed at $15.00/hour in 15 minute increments

Print a Copy of the Medical Records HIPAA Release Form

Click here to print a Medcal Records HIPAA Release Form (pdf) and then fax / mail / bring it by the office.


› HIPAA Release Form

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