Medical Record Request
All patient health care information at Austin Pediatric Surgery is strictly confidential. Therefore, medical records cannot be released to any person or organization without the consent of the patient or the patient’s legally authorized representative (unless authorized by law).
To receive a copy of your child’s health information, an authorization to release medical information must be signed and dated by the parent or legal guardian. If you wish to obtain a copy, please complete the Medical Records Request (pdf) form and fax, mail, or bring to our office. Or you may provide the following information in a letter format.
- Patient name and address
- Patient date of birth
- Name of person to whom information is to be disclosed and relationship to patient
- Address of person to whom information is to be disclosed
- Specific health information to be disclosed
- Purpose for the release of information
A fee of $25.00 will be assessed to cover the cost of copying and sending your record. If the records are being faxed or mailed to another medical facility, there is no charge.
Submitting An Authorization
Completed authorization forms may be submitted to Austin Pediatric Surgery by mail, in person, or by fax.
Austin Pediatric Surgery
1301 Barbara Jordan Blvd Suite 400
Austin, TX 78723