Welcome to ATX Primary Care

Opening Hours : Monday to Friday - 7:30am to 4pm
  Contact : (512) 452-2506

Plan Your Visit

Set Your Appointment

Call (512) 452-2506 during regular business hours.

Office Hours: Monday – Friday – 7:30am to 4:00pm
Click to Call (512) 452-2506

Please advise our staff if you are being referred or have had a change in your insurance policy. Please have the following information available: Full name, date of birth, and insurance information.


Payment & Insurance Information

Please have your insurance card available while making your appointment. Please advise us of any of the following: Subsidiary Medicare program, Secondary Insurance policy, or Out-of-State policy. Our office staff will contact your insurance provider to verify all benefits. However, it is the patient’s responsibility to make sure that their policy is active and to be aware of any limitations of coverage. See our Billing & Insurance page for more info. Want to pay your bill online via credit card? You can also make a Secure Online Payment here.

Complete and Submit Our Office Forms

Medical Records Release TO ATX Primary Care

  • MM slash DD slash YYYY
  • I Hereby Authorize Release of Information from:

  • This information may be sent to and used by the following individual or facility:

    ATX Primary Care
    Robert Raley, MD Aline C. Zeringue, ACNS-BC Mandy Mishra, ACNS-BC Eileen M. Costa, FNP-C
    2301 W. North Loop Blvd.
    Austin, TX 78756
    (P) 512-452-2506 (F) 512-371-0187
  • MM slash DD slash YYYY

Or download this form and bring it with you

Medical Records Release FROM ATX Primary Care

Or download this form and bring it with you

New Patient Registration


Today's Date(Required)
Date Of Birth(Required)
Mailing Address(Required)

Insurance Policy Information

***Patients are required to present proof of insurance coverage PRIOR to services, otherwise patient will be responsible for full payment of services at time of visit***

Date Of Birth

Medical History

Please note if you have ever been diagnosed with the following:
Please check if you have had the following, and enter the approximate date(s) below:
Please check if you have had the following, and enter the approximate date(s) below:

Females Only:


List any family members who have had the following:


Are you:


Dear Patient,

These HIPAA forms are required by law. Here are the instructions: You must at least look at the HIPAA Consent documents. Although you may refuse to sign, that event has to be noted on the documents (by you or us) and filed in your record.

The Medical and Financial Agreements section is required by this practice as condition of treatment and must be signed at this time for us to agree to treat you.

Medicare and Tricare Patients You have additional documents that must be signed every time you have a physical.

We sincerely regret the inconvenience and thank you for understanding.

ATX Primary Care

Medical and Financial Agreements

Today's Date(Required)

Today's Date(Required)

Definition of a Well-Care Visit

Insurance companies and Medicare have defined a well-care visit as a visit for preventative care. These recommendations apply to healthy people without disease or physical symptoms. If tests or services beyond the scope of a well-care visit are provided, then additional charges will be incurred for those services.

The choice to address both well-care and medical issues is offered for the convenience of avoiding 2 visits. You may prefer to address your medical conditions at a separate visit. If so, please advise the medical assistant when you are brought to an exam room.

Please remember that Medicare has its own defined wellness coverage guidelines.
Go to http://www.medicare.gov/coverage/preventative-visit-and-yearly-wellness-exams.html to review coverage service requirements.

Your scheduled appointment today is for an ANNUAL EXAM, which is a well-care visit. Wellness exams are often paid 100% by your insurance company. This is for the purpose of assuring all the recommended health screening tests and procedures have been done. These annual visits are not normally for treating conditions or disease. Unfortunately, it is impossible for us to know your contract with your insurance company; we cannot advise you if your insurance company is going to cover the charge for an annual exam. If tests or services beyond the scope of a well-care visit are provided, then you will incur additional charges.

  • If you are uncertain of your coverage, please contact your insurance company regarding benefits
  • I fully understand and agree to pay Dr. Robert Raley/ATX Primary Care for this service if my insurance company denies my claim.
A review of your current health and medical history Treatment or consultation for a specific medical condition
Counseling about ways to improve your health Recommendations for treating a symptom is not considered part of a well-care visit
A physician exam tailored to your preventative care needs Medication refills for current medical conditions
Immunizations and screening tests, if needed (billed separately) Disease care/management
Today's Date(Required)
Date Of Birth(Required)
This field is for validation purposes and should be left unchanged.

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Practice Policies


Services Provided

ATX Primary Care employs licensed health care providers to provide diagnosis and management for adults in accordance with Texas laws. Following an initial assessment, discussion of treatment options and recommendations will occur. Together, a decision on the best course of action will be made. Primary care is a partnership and requires active participation from both patients and providers.

Insurance / Financial Agreement

ATX Primary Care and its providers to not contract with commercial insurance plans. ATX Primary Care is not contracted with Medicaid or any Medicare Advantage Plans. Payment is due at the time services are rendered and is based on the fees outlined prior to starting treatment. For patients with insurance, ATX Primary Care and its providers are considered "out-of-network". A billing statement will be available for patients at the completion of the visit. Patients may choose to submit this statement to health insurance carriers to receive reimbursement at "out-of-network" rates. Outside of providing the billing statement and the visit documentation notes with appropriate diagnosis codes, we do NOT participate in the re-imbursement process and will not submit claims directly to insurance carriers.

We are considered in-network with "traditional" Medicare. As a service to those patients with traditional Medicare, we will bill Medicare directly. We will collect any co-pays at the time of the visit or bill for those co- pays. Patients are still responsible for any co-pays, any co-insurance, and meeting all required deductibles and out of pocket expenses per the terms of Medicare.

There will be a $40 fee for any returned check.

Prescription Refills

Prescriptions will be sent electronically to the pharmacy. If refills are needed, patients should first contact the pharmacy to request a refill. If there are no further refills available on a medication, patients should call the office. Patients should allow 48-72 hours for refill requests to be processed and should request these during normal business hours, Monday – Thursday, 7:30-5:30.

Prescription of Controlled Medications

ATX Primary Care does not prescribe ANY schedule II drugs, including opioids or stimulants, or medical cannabis. Prior to initiation or continuation of any controlled medications, such as opiate derivatives, benzodiazepines, hypnotics and other controlled substances, Federal and State databases (Prescription Monitoring Program) will be accessed and routinely monitored.

Patients who require chronic pain medication will be referred to a pain medicine specialist.

Patients with chronic psychiatric illnesses may be referred to our psychiatric, psychologist, or therapy specialist colleagues.

Prescription medication forgery, misuse and/or diversion of controlled medications are grounds for termination from the practice.

Cancellations, No-Shows, and Late Arrivals

ATX Primary Care understands the complexities of life and unforeseen changes that may occur. Patients are asked to kindly give 24-hour notice if they are unable to make a scheduled appointment. Patients arriving late to scheduled appointment times may be asked to wait or reschedule.

Emergencies and After-Hours

In the event of a medical emergency, patients should call 911 or go to the nearest emergency department. Currently, ATX Primary Care does not provide after-hours access or services. Patients should contact the office during normal business hours, Monday – Thursday, 7:30-5:30.

Treatment of Staff

ATX Primary Care has a zero-tolerance policy for any disrespect, rudeness or abusive behavior toward staff or employees. Behavior as such will result in immediate termination from the practice.

Communication by Telephone

There are times we will need to communicate with you by telephone. If you are not immediately available at those times, we will need permission to leave detailed messages on your primary phone concerning your care. Please indicate your preferences below so we are clear about your wishes on this matter.

Voicemail choice:

Medical and Financial Consent – Signature Required

ATX Primary Care employs licensed health care providers to provide diagnosis and management for adults in accordance with Texas laws. I authorize the providers at ATX Primary Care to provide me with reasonable and proper medical care.

I understand that I am financially responsible for all charges that are due at the time services are rendered. I understand that ATX Primary Care, unless I have traditional Medicare, will NOT file charges with my insurance company. I am fully responsible for submitting and collecting on any charges or claims that may be reimbursed by my insurance company.

I have read a copy of the practice policies outlined above. I have been given an opportunity to ask questions and understand the policies as they are described.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Date Signed:(Required)

Or download this form and bring it with you

Medical Records Release TO ATX Primary Care

Or download this form and bring it with you

Medical Records Release FROM ATX Primary Care

Or download this form and bring it with you

Personal Representation Designation

*To view the PDF forms the Adobe Reader is required. If you are having issues viewing these files please download and install by clicking here.


Bring Any Medications & Previous Records

You are welcome to have your records faxed to our office at (512) 371-0187. However, to ensure the availability of your information and to prevent a delay in your visit, we recommend that you obtain a printed copy of your records and bring it with you. Please also bring any medications you are taking.


Map & Directions

From Mopac (Loop 1)

Take RM 2222/Northland Dr. toward the center of Austin.
Turn right onto Shoal Creek Blvd.
Turn left left onto Hancock Dr.
Turn left onto Woodview Ave.
Take the 1st right onto North Loop Blvd W.
Destination will be on the right.

From I-35

Take 2222/E Koenig Ln (to the west)
Turn left onto N Lamar Blvd.
Take the 3rd right onto N Loop Blvd (or) W North Loop Blvd.
Continue to follow W North Loop Blvd.
Destination will be on the left.