Patient Forms

Medical Records Transfer

Prime Healthcare Providers will be happy to furnish a copy of your medical records to your new physician in the community upon your written authorization and payment of the administrative costs associated with doing so.

We follow the recommendations set forth by Texas State Law & HIPAA Guidelines (see below):

165.2. Medical Record Release and Charges.

(e) Allowable Charges.

(1) The physician responding to a request for such information shall be entitled to receive a reasonable, cost-based fee for providing the requested information. A reasonable fee shall be a charge of no more than $25 for the first twenty pages and $.50 per page for every copy thereafter. If an affidavit is requested, certifying that the information is a true and correct copy of the records, a reasonable fee of up to $15 may be charged for executing the affidavit. A physician may charge separate fees for medical and billing records requested. The fee may not include costs associated with searching for and retrieving the requested information.

(2) A reasonable fee, shall include only the cost of:

(a) copying, including the labor and cost of supplies for copying;

(b) postage, when the individual has requested the copy or summary be mailed;

(c) preparing a summary of the records when appropriate.

Therefore based upon these provisions, we will calculated your medical transfer fee as follows:

We ask that you please make your check payable to your doctor of record and we will make that known to you in our actual response letter and statement.

We do not bill for this service after the fact, so payment must be received prior to sending your records out. Please call our office to determine the number of pages in your chart that require copying and we will give you the actual cost.

If you have not already done so, please send your HIPAA compliant signed authorization to release records form and instructions where to send mail them including an expiration date on your consent. Should a form be needed, please contact my office or your new physician for a written release form.

All medical records will be forwarded upon a completed and signed authorization including an expiration date and the appropriate fee as previously identified herein. For your convenience, we do accept major credit cards.

Please allow 7-14 days to complete this process. Please call us, should you need any further assistance.

We extend to you my best wishes for your future health.

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