Patient Resources

Release of Information (ROI) Forms

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For Patients

  • Complete a medical records Release of Information Form:
    A HIPAA-compliant Release of Information Form is required whenever you request copies of your medical record.
    (For your convenience we provide our patient forms online. Please bring the completed form(s) with you to your appointment. The forms below can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.)
  • Review & pay fees:
    Texas state allows for the following fees for the copying and releasing of medical records in the case of a patient request:
    Printed Copies:
    $0.39 per page
    Plus any postage costs (The postage will not exceed $15.00)
    Electronic Copies:
    First 500 pages: not to exceed $25.00
    More than 500 pages: not to exceed $50.00
    Austin Regional Clinic is capping the fee at $25 for a two-year abstract of your medical record including up to five years of diagnostics regardless of page count.
    If you require your entire record, the fee will be according to Texas state statute.
  • Send the completed form to:
    ARC – Release of Information
    6937 N IH 35
    Ste 500
    Austin, Texas 78752
    Ph: 770-810-8908
    Fax: 404-855-4977
  • Send Payment to:
    Via Mail:
    PO Box 409900
    Atlanta, GA 30384
    Via Phone:
    1-770-360-1700
    Via Website:
    www.healthportpay.com
    If payment in full does not accompany the request, an invoice will be sent within 5 days of receipt of the Authorization to Release Records. Payment can be made by check or credit card. If you have any questions please call us at 770-810-8908 and we will handle your call promptly.
  • Receive you records by mail or pick them up in person:
    By Mail:
    We will mail your records upon payment in any of the above-mentioned means.
    In Person:
    Please call 770-810-8908 in advance, to eliminate a long wait time.
    Monday - Friday 9:00 a.m. - 4:00 p.m.
    6937 N IH 35
    Ste. 500
    Austin, TX 78752
    Please have photo identification available.

For Insurance Companies, Attorneys, APS Services or Disability Services

Please send your request to our Release of Information Processing Center (no prepayment is necessary):

ARC - Release of Information
6937 N IH 35
Ste. 500
Austin, TX 78752
FAX: 512-380-9833

If you have any questions regarding the process for requesting records and/or associated fees, please contact our Release of Information Processing Center at 770-810-8908.

Requesting Your Medical Records Be Sent to ARC

If you are a new patient establishing care at ARC and will need your medical records transferred from an outside doctor to an ARC doctor, the following form is available for your convenience:

Granting Others Access to Your Medical Records

If you would like to grant access to your ARC medical records to your spouse or any other individual(s) for purposes other than treatment, payment, or healthcare operations, please complete the form below.

Please note that the form below can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

Mail the completed form to:

Privacy Officer
Austin Regional Clinic
4515 Seton Center Parkway, Suite 215
Austin, TX 78759

Thank you. We look forward to serving you.



We Want To Hear From You

Send us our comments or questions, or call us at

*By using this form to communicate with austin Regional clinic (ARC), the information will be transferred over the internet. ARC uses Transport Layer Security (TLS) encryption in order to secure the information you send to us over the internet. There may be times when we cannot respond to your request in email format and another method of communication will be used. For your privacy, please consider the information you include, and who, besides you, may have access to your email account.