Clinic Forms
- Notice of Privacy Practice - updated November 2022
- Notice of Privacy Practice (Español) -updated November 2022
- Patient Consent and Release for Screening
Patient Referral Forms
- UTHA Referral Form - Print and complete this form and fax to: 512-495-5680
- Comprehensive Memory Center - Due to a current waitlist of 4-6 months, at this time only internal referrals from UT Health Austin providers are being accepted.
- Livestrong Cancer Institutes and Surgical Oncology - Print and complete UTHA Referral Form and fax to: 512-495-5709
- Authorization To Release Records Form - to expedite the referral process
Medical Record Forms
- Authorization To Release Records Form - to allow UTHA to share your medical record with another provider
- Autorización para divulgar información de la salud
- Authorization To Receive Records Form - to allow UTHA to request your medical forms from another provider
- Autorización para recibir registros médicos
- Authorization to Share Health Information - to allow your provider to discuss (verbally) your health information with another provider