Texas Medical Records Release Form 2
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THE UNIVERSITY OF TEXAS AT AUSTIN

Authorization for Release of
Medical Records

DIVISION OF STUDENT AFFAIRS

university health services

I authorize the following protected health information to be released from the medical record of:

LAST NAME (PLEASE PRINT)

FIRST NAME (PLEASE PRINT)

EMAIL ADDRESS

DATE OF BIRTH

UTEID

TODAY’S DATE

PHONE NUMBER

Release Records
 From
 To

University Health Services
H.I.M. - Records Release
P.O. Box 7339
Austin, TX 78713-7339
Fax 512-475-8282
Phone 512-475-8226

Release Records
 To
 From

NAME/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

FAX

 Please mail my records
 Please call when my records are ready for pick-up
 NOTE: Fee schedule available at healthyhorns.utexas.edu/records

ZIP CODE

 Please fax my records

I understand that to the extent that any recipient of this information, as identified above, is not a “covered entity” under Federal or
Texas privacy law, the information may no longer be protected by Federal and Texas privacy law o