Release of Information

The release of Information Form- Please print, fill out all sections and submit.  For best results, point cursor to the left of the image (in the dark gray area), right click and choose print.

The release of Information Policies

Our office receives numerous requests for medical records each week and we do the best we can with our limited staff to ensure that all records transfers are processed with care to ensure your privacy, timely response and adherence to applicable statutes and guidelines from governing entities.  Every request is carefully reviewed and acted on in a process that involves both the physician and a staff member.

Due to the time and effort involved, there is a fee for these services. These fees are determined in accordance with guidelines established by the Texas Medical Board (TMB) and the Office of Civil Rights (OCR).  Fees are determined based on the specifics of the request, including the purpose, destination, and expense of producing the requested documents. We want you to understand the process fully as you request these materials.

Regarding specific requests:

  1. Release directly to the patient. Transfer fees adhere to OCR fee guidelines.  The charge is either a flat fee of $6.50 or for more extensive records that require extended staff time to produce, our calculated actual costs for producing the materials plus any postage involved.
  2. The release of medical records to another physician or healthcare facility. If we have referred you to another physician, we will usually provide recent, pertinent records needed for the consultation at no charge.  If more extensive records are requested, or if the transfer is to another physician to whom we have not referred you, OCR fee guidelines apply.  Records are transferred within 15 business days of receipt of a properly executed release of information form and applicable fees. Requests for emergency transfers will be honored as quickly as possible if the receiving facility or doctor notifies us that emergency access to records is needed.  Emergency transfers are still subject to transfer fees.
  3. The release of records to non-physician third parties (insurance company, attorney, etc.) .  This is subject to TMB approved fees.  These transfer fees are calculated as follows:  $25 for the first 20 pages, then 50 cents per page after the 20th page.
  4. The release of information for use in supporting a claim for Social Security Disability. There are special rules that govern the production of records used for documentation in a disability claim that is too detailed to print here. Ask your doctor’s medical assistant about fees and procedures for this type of document production.
  5. Dictated reports, forms, requested letters, certain types of appeals to insurance companies, and other requests beyond simple production of copies of your medical record. These charges vary with the complexity and time involved by the physician and staff. You should inquire about an estimate of these charges at the time of the request.