The Texas State Board of Medical Examiners approves an initial fee of $25.00 for the *first 20 pages of a record and $.50 per page thereafter. These fees apply if an attorney, insurance carrier or third party on you behalf request copies. Fifteen days should be allowed for our office to provide these records after a signed authorization and payment has been received. The fee cost for the release of medical records directly to a patient is $6.50.
I understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it. I understand that in any event this authorization expires automatically in ninety days fro the date of this signature.
The fee is waived if the records are used to support an application for disability or benefits under: AFDC, Medicare, Medicaid, Social Security Administration or Federal Old age Survivors Insurance. I have attached a statement which confirms that an application or appeal has been filed or in pending.
The patient agrees that a photocopy, CD or fax copy authorization and records may be considered valid.