Release of Information (ROI) Forms
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.)
Authorization for Use or Disclosure from ARC
Release of Information Instructions
Review & pay fees:
Austin Regional Clinic and its release of information vendors comply with all federal and state laws regarding fees for records. If payment is required, you will be contacted by ARC or the vendor with further information.
Austin Regional clinic is capping the fee at $25 for a two-year abstract of your medical record including three to six month of diagnostics, regardless of page count.
Send the completed form to:
ARC – Release of Information
9503 Brown Lane
Bldg 4, Ste 101
Austin, Texas 78754
** At this time, we cannot accept records via any carrier other than USPS. If you need another delivery method (ie. FedEx), please contact the phone number listed above to make arrangements. We will continue to evaluate the situation and will make updates as needed.**
Send payment to:
If you have any questions please call us at 512-483-9598 and we will handle your call promptly.
Receive your records by mail or pick them up in person:
We will mail your records upon payment in any of the above-mentioned means.
At this time, we cannot allow records to be picked up in person due to COVID-19 concerns. We will continue to evaluate the situation and will make updates as needed.
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
9503 Brown Lane
Bldg 4, Ste 101
Austin, TX 78754
If you have any questions regarding the process for requesting records and/or associated fees, please contact our Release of Information Processing Center at 512-483-9598.
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:
Authorization for Release and Disclosure of PHI to Austin Regional Clinic Form
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.
Authorization for Use and Disclosure of Protected Health Information to a Spouse or Other Individual(s)
Please mail the completed form to your ARC physician's clinic.
Thank you. We look forward to serving you.
Download Adobe Reader to view and print documents.