RECORDS & FORMS

There is a $25.00 charge for medical records. Please allow up to 15 days in order for us to have the records copied. There is no limit to the amount of records that we will copy. There is a $5.00 charge to print a copy of a shot record for a patient, this is why we encourage parents to bring in their child's shot records each visit. Call 468.6277 to request copies or you may fill out our online request.

There will be a $20.00 fee for filling out all FMLA paperwork, Medical Action Plan, or any other form which requires the doctor’s time to fill out or process.

Please take a moment to print the following forms prior to your first visit: the Patient Information Sheet and the HIPAA Signature Form. We have also included specialty forms that can be printed upon the request of your physician, patient information forms that you can view and read, and some informational pieces regarding immunizations.

Please contact us if you have any additional questions.

PATIENT FORMS - Please print

Patient Information Sheet
HIPPA Signature Form
Texas Vaccines for Children Eligibility Screening Record

SPECIALITY FORMS - Print upon request of physician

Medical Records Release Form

PATIENT INFORMATION - These are for your information, you do not need to print

HIPPA Privacy Notice
Amarillo Children's Clinic Welcome Letter
Medical FAQ
Patient Bill of Rights

© Copyright - Amarillo Children’s Clinic
#17 Care Circle | Amarillo, Texas USA | 79124 
806.468.6277
ACC FAQ's, Policies and Disclaimers
Privacy Policy

PATIENT NON-DISCRIMINATION POLICY
Any individual shall not be discriminated against because of race, color, creed, religion, sex, age, sexual preference, national origin, citizenship, marital status, disability, veteran status or any other status or characteristic protected under applicable federal, state or local laws. Acts of and/or harassment based on any of those factors are totally inconsistent with our philosophy of doing business and will not be tolerated at any time.
*ATTENTION: Language Assistance Available: Español (Spanish) | 繁體中文 (Chinese) | Tiếng Việt (Vietnamese) | 한국어 (Korean) | Tagalog (Tagalog – Filipino) | Русский (Russian) | العربية (Arabic) | Français (French) | Deutsch (German) | 日本語 (Japanese) |   فارسی (Farsi) | हिंदी (Hindi) | ພາສາລາວ (Lao) | ગુજરાતી (Gujarati)
Language assistance services, free of charge, are available to you. Call: 1-800-368-1019 or TTY: 1-800-735-2989

 

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