Clinic Forms
- Notice of Privacy Practice
- Notice of Privacy Practice (Español)
- Patient Consent and Release for Screening
- Occupational Health and Injury Form
- Occupational Health and Injury Form (Español)
- Travel Clinic Medical Questionnaire Form
- Travel Clinic Medical Questionnaire Form (Español)
Patient Referral Forms
- UTHA Referral Form - Print and complete this form and fax to: 512-495-5680 (this form may be used with all clinics except Comprehensive Pain Management)
- LIVESTRONG Cancer Institutes - Print and complete UTHA Referral Form - FAX to: 512-495-5709
- Comprehensive Pain Management Referral Form - Print and complete this form and fax to: 512-495-5457
- 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