Medical Information Release Form ("MIRF")

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In order for providers to be able to communicate with us regarding your medical file under applicable state and federal law, we need to obtain a hand signed Medical Information Release Form ("MIRF") from you.

If you have been instructed by Karis or your plan provider to submit a MIRF to Karis, please fill out the web form below and click the Print This Form button. You must turn off any popup blocker for this site before printing or downloading this form. After printing, please sign the release and then fax or mail it to us at the fax number or mailing address provided on the bottom of the form.

If you are not connected to a printer at the moment, please click on the Save This Form button to save the form to print later. If you would like to download a blank MIRF, please click here.

Medical Information Release Form

*Patient's Name:

*Social Security Number (###-##-####):

*Date of Birth (mm/dd/yyyy):

Mailing Address:

City:

Zip Code:

The undersigned hereby grants permission to The Karis Group to discuss any and all medical bill related information with any medical practitioner, hospital, facility, insurance company or any other agency that has medical records or knowledge of the medical records of the undersigned and/or the dependents listed herein for the purpose of The Karis Group negotiating medical bills on the undersigned’s or dependent’s behalf.

The undersigned hereby authorizes any medical practitioner, hospital, facility, insurance company or any other person or entity that has medical records or knowledge of the medical records of the undersigned and/or the dependents listed herein, to release such information upon request to The Karis Group for the purpose of The Karis Group negotiating medical bills on the undersigned’s or dependent’s behalf.

The undersigned understands that:

I may revoke this medical information release at any time, in writing, but the release shall remain valid until revoked or upon the expiration of one (1) year after the release is executed, whichever occurs first.
This release may include medical records of treatment for physical and/or emotional illness, except psychotherapy notes, including treatment of alcohol or drug abuse.
The Karis Group will maintain the privacy of any information obtained and will not disclose such information to any other person or entity except as necessary to effectuate service or by express written permission by me.
A copy of this form, including a facsimile, may be used in place of the original.

I acknowledge that I have read and understand this Medical Information Release Authorization. Further, I authorize the disclosure of my protected health information in accordance with the terms in this Authorization.

Signature of Patient:

Printed Name of Patient:

*Date:

Fax or mail the completed form to The Karis Group:
Fax: 512-292-5700
Mail: The Karis Group, 3755 S Capital of Texas Hwy Ste 240, Austin, TX 78704

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