Patient Forms

The Patient Registration process and online form provides us with the information to set up your billing account with ARC. Information required includes demographics of each patient, responsible part for payment, and any health insurance information applicable to the patient.

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In collecting demographic information, ARC adheres to the standards that were established by the U.S. Office of Management and Budget (OMB) in 1997. It is the same standard used by the U.S. Census Bureau. The OMB requires five minimum categories for data on race:

• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White

The OMB requires two minimum categories for data on ethnicity:

• "Hispanic or Latino"
• "Not Hispanic or Latino"

A patient's response to the race and ethnicity questions are based on self-identification and the patient may choose more than one race.

MyChart registration & caregiver forms

Visit the MyChart® Registration & Caregiver Forms page for more information on how you can sign up for MyChart® and how to also gain access to your child or loved one's medical information. MyChart® is ARC's easy-to-use patient portal that allows quick and easy access anywhere and anytime.

Patient information and consent for treatment of a minor

Please fill out a Consent to Medical Treatment of a Minor form and have your child bring it to the appointment if you are the parent of a minor and would like your child to be seen by any of our providers without your presence.

Release of information (ROI) forms

Please visit the Release of Information (ROI) page for more information and to find the ROI form that best suits your needs. Whether you are a new patient requesting a transfer of your medical records to Austin Regional Clinic or an established patient requesting your medical records from ARC, a Release of Information Form is required.

Health history forms

Health History forms are for basic background health information. It will be reviewed by your doctor and nurse as soon as it is received, is confidential and part of your medical record.

For your convenience we provide our patient forms online. Please bring the completed form with you to your appointment.

Patient Forms

• Adult health history forms

  Print theAdult Health History form, complete it, and bring it to the office.

  The form can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

• Allergy & Asthma patient forms

  Please bring the completed Allergy-Asthma Patient form with you to your appointment.
  
  Allergy and Asthma Health History Form (English-Spanish)
  
  Allergy and Asthma New Patient Questionnaire

• Cardiology patient forms

  All office visits after 5:00pm Monday – Friday and all weekend and holiday visits include an office visit fee plus a $30 After Hours fee that some insurance plans cover. If your insurance plan does not cover the After Hours fee, we will send a billing statement for your review and payment.

  Cardiology Health History Form(English and Spanish)

• Dermatology patient forms

  Please bring the completed Dermatology Patient form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Dermatology Health History Form (English and Spanish)

• Ear, Nose and Throat (ENT) patient forms

  Please bring the completed Ear, Nose and Throat (ENT) Patient Form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Ear, Nose & Throat (ENT) Adult Health History Form (English and Spanish)

  Ear, Nose & Throat (ENT) Pedi Health History Form (English and Spanish)

• Endocrinology patient forms

  Please bring the completed form with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Endocrinology/Fertility Health History Form (English and Spanish)

• Gastroenterology patient forms

  Please bring the completed Gastroenterology Patient form with you to your appointment.

  Gastroenterology Health History Form (English and Spanish)

• General Surgery patient forms

  Please bring the completed General Surgery Patient form with you to your appointment.

  General Surgery Health History Form (English and Spanish)

• Medicare Wellness visit forms

  Please fill out a patient history form for your annual Medicare Wellness Visit. Medicare requires a new form each year. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Medicare Wellness Questionnaire - Extensivist
  Medicare Wellness Questionnaire - FM/IM
  Medicare Wellness Checklist

  This advanced directive form is designed to help you communicate your wishes about medical treatment at some time in the future when you are unable to make your wishes known because of illness or injury.

  Advance Directives form and information

  Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself.

  Medical Power of Attorney form and information
  Poder Notorial Médico
  Out of Hospital (DNR) Form
  Orden De No Reanimar Fuera Del Hospital (OOH DNR)

• Orthopedic patient forms

  Please print and complete the appropriate form below, and bring to your consultation for your doctor and nurse to review. It will provide the basic background orthopedic health information that will be a confidential part of your medical record.

  Orthopedic Health History Form

  Established New Orthopedic Problem

  Post Op/Follow up Visit

  Follow up Visit - for Dr. Tipton Patients

  Sports Medicine Health History Form - for Drs. Zinn & Hairgrove Patients

• Pediatric health history forms

  For your convenience we provide our patient forms online. Please use the forms below if you are a new patient to Austin Regional Clinic, and bring the completed form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Pedi Female 9-17 Health History (English and Spanish)
  Pedi Female Under 9yrs Health History (English and Spanish)
  Pedi Male 9-17 Health History (English and Spanish)
  Pedi Male Under 9yrs Health History (English and Spanish)

• Podiatry patient forms

  Please bring the completed Podiatry Patient Form with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Podiatry Health History Form (English and Spanish)

• Preventive Care forms

  Austin Regional Clinic works hard to give the highest quality of care by providing yearly, physical examinations. Most insurance companies cover one wellness exam per year at no cost to the patient, including certain tests to detect disease in early stages or to prevent disease.

  Unfortunately, most insurance companies will not cover tests unrelated to the physical and can choose to not cover the full cost of the office visit for separate health concerns discussed during an exam.

  Please review the forms below to see examples of treatments or discussions that may not be covered in a physical examination.

  ARC Preventive Visit Charges Notice

  Cargos de Visitas Preventivas

  ARC Preventive vs. Acute Care FAQs

  Cuidado Preventivo vs. Cuidado Intensivo FAQs

• Requesting your ARC medical records

  Release of information (ROI) forms

  For patients

  1. Complete a medical records release of information form:
     
     A HIPAA-compliant Release of Information Form is required whenever you request copies of your medical record.
     
     (For your convenience we provide our patient forms online. Please bring the completed form(s) with you to your appointment. The forms below can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.)
     Authorization for Use or Disclosure from ARC
     Release of Information Instructions
  2. Review & pay fees:
     

     Austin Regional Clinic and its release of information vendors comply with all federal and state laws regarding fees for records. If payment is required, you will be contacted by ARC or the vendor with further information.

     Austin Regional clinic is capping the fee at $25 for a two-year abstract of your medical record including three to six month of diagnostics, regardless of page count.
  3. Send the completed form to:
     
     ARC – Release of Information
     9503 Brown Lane
     Bldg 4, Ste 101
     Austin, Texas 78754
     Ph: 512-483-9598
     Fax: 512-406-6269
     

     ** At this time, we cannot accept records via any carrier other than USPS. If you need another delivery method (ie. FedEx), please contact the phone number listed above to make arrangements. We will continue to evaluate the situation and will make updates as needed.**

  4. Send payment to:
     
     If you have any questions please call us at 512-483-9598 and we will handle your call promptly.
  5. Receive your records by mail or pick them up in person:
     
     By mail:
     We will mail your records upon payment in any of the above-mentioned means.
     
     In person:
     
     At this time, we cannot allow records to be picked up in person due to COVID-19 concerns. We will continue to evaluate the situation and will make updates as needed.

  For insurance companies, attorneys, APS services or disability services

  Please send your request to our Release of Information Processing Center (no prepayment is necessary):

  ARC - Release of Information
  9503 Brown Lane
  Bldg 4, Ste 101
  Austin, TX 78754
  Ph: 512-483-9598
  FAX: 512-406-6269

  If you have any questions regarding the process for requesting records and/or associated fees, please contact our Release of Information Processing Center at 512-483-9598.

  Requesting your medical records be sent to ARC

  If you are a new patient establishing care at ARC and will need your medical records transferred from an outside doctor to an ARC doctor, the following form is available for your convenience:

  Authorization for Release and Disclosure of PHI to Austin Regional Clinic Form

  Granting others access to your medical records

  If you would like to grant access to your ARC medical records to your spouse or any other individual(s) for purposes other than treatment, payment, or healthcare operations, please complete the form below.

  Please note that the form below can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Authorization for Use and Disclosure of Protected Health Information to a Spouse or Other Individual(s)

  Please mail the completed form to your ARC physician's clinic.

  Thank you. We look forward to serving you.

• Rheumatology forms

  Please bring the completed Rheumatology Patient Form with you to your appointment. You can print the form below, fill it out, and bring it with you to your consultation.

  Rheumatology Health History Form (English and Spanish)