Patient Forms

Our team has provided forms for your upcoming appointment. We also offer the ability to request your medical records online. If you have any questions, don’t hesitate to contact the office where you have your scheduled appointment.

New Patient Forms

Please print and complete the appropriate forms as directed at least one day prior to your appointment. For the first visit, please bring your insurance card and plan to arrive 10 to 15 minutes before your scheduled time.

English

• • Patient Registration Form
  • Medical History Form
  • Patient Portal Consent
  • Consent to Release Protected Health Information & Assignment of Benefits
  • Electronic Communication Consent Form
  • No Show/Late Cancellation Policy
  • Drug Prior Authorization Policy
  • Financial Policy
  • Notice of Privacy Practices 

Spanish

Haga clic aquí Paquete de nuevos paquetes de pacientes para imprimir los 5 formularios al mismo tiempo.

• Informacion del Paciente
• Consentimiento Para Divulgar Información Medica Privada y Asignación De Beneficios
• Historial Medica
• Poliza Financiera
• Portal del Paciente
• Póliza de No Presentarse y Cancelación de Ultimo Aviso
• Política De Consentimiento De Correo Electrónico Del Paciente

Medical Records Request

Urology Austin is  partnered with the Healthmark Group to provide a secure, on-line method to request medical records. On-line requests are also accessible to third party vendors acting on behalf of patients.

Read through the following steps in order submit your medical record request:

• Click this link to be directed to Healthmark’s secure site. New users will need to create an account.
• Once on Healthmark’s site, choose “Requestors”.
• Log into the MedRelease tool found on the Healthmark site. New users will need to create an account.
• After logging into MedRelease, choose “Submit Request” (found on the left-hand side of the page) to fill out a HIPAA-Compliant Medical Records Release Authorization form.
• Once this on-line form has been completed, choose “Authorize Release” located at the bottom of the page.

After authorizing the release of records, your request will be processed by the Healthmark Group. Once complete, you will be notified by email, or through standard mail, on how to retrieve your records. Patients who supply an email address will receive their notifications faster than by standard mail.

Medical records status or help with requesting medical records

Patients who have questions about completing the medical records request, or who would like to check the status of their request can contact the Healthmark Group at:

By Phone at 800-659-4035

By Email at status@healthmark-group.com

Website: https://www.healthmark-group.com/