!
Westlake Lakeway
2499 S Capital of Texas Hwy Bldg B, Ste. 100 2501 RR 620 S Ste.220
Austin, TX 78746 Lakeway, TX 78734
Phone: 512.328.7666 Fax: 512.328.3547 Phone: 512.328.BUZZ
____________________________________________________________________________
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I hearby authorize the following information to be released from the medical records of:
Patient Name ____________________________ Date of Birth ____________________
Patient Name ____________________________ Date of Birth ____________________
Patient Name ____________________________ Date of Birth ____________________
Patient Name ____________________________ Date of Birth ____________________
Please release medical records TO / FROM (please include the following information):
Business/Name _____________________________________________________
Address ___________________________________________________________
City _________________________ State __________ Zip Code ______________
Phone # (____) ______________________________________________________
Reason for requesting medical records____________________________________
Please check information to be released:
____ Immunization record
____ Entire medical record
____ Other:______________________________________________________
There is a $25.00 fee that applies per patient if you are requesting/transferring medical records from
Bee Caves Pediatrics.
___________________________________ ______________________
Signature of Patient or Legal Guardian Date
