SAN ANTONIO * NEW BRAUNFELS*FREDERICKBURG * MARBLE FALLS * SAN MARCOS
“RELIEVING PAIN, RESTORING HOPE”
210-582-6600 phone 210-582-6601 fax
Toll free phone: 866-384-5470 * Fax 866-384-5471
www.hillcountrypain.com
Please print out this form and fax to us (866-384-5471)
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Patient name:
Social Security:
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/
Please print name legibly
DOB:
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/
I hereby authorize the release of my medical records to:
Requesting medical records from:
HILL COUNTRY PAIN ASSOCIATES
14800 San Pedro Suite 115
San Antonio, Texas 78232
Requested records (check all that apply):
Labs
X-Rays/Mri/Ct Reports
Last 5 Progress Notes
All medical records
Other:
For the purpose of:
Patient Signature:
Date:
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/
This authorization will automatically expire two (2) years from the date signed.
In order to comply with regulations for Health Insurance Portability and Accountability Act (HIPAA) governing the
confidentiality of patient information, a fully completed, HIPAA compliant, Authorization to Release Medical
Records must accompany each request for medical records even though you may have already obtained a signed
consent from the patient.
We are sorry for any inconvenience this may cause, but the laws were entacted to protect the confidentiality of
medical information. Physicians must comply with HIPAA privacy standards by requiring a fully completed form
with all required information before releasing patient information. Thank you for your cooperation.