Medical Records Request

Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Email
example@example.com
Medical Records Request Form

Authorization for the Disclosure of Protected Health Information
By signing this authorization, I authorize the following Provider and/or Facility to use and/or disclose the following Protected Health Information (PHI).
Practice Name / Physician Name*
Contact Person
Address*
Phone Number*

Area CodePhone Number
Fax Number*

Area CodeFax Number
What PHI may be disclosed (type ALL for the entire chart)*
Specifically describe the information to be released, i.e.: date(s) of service, level of detail to be released, origin of information, etc
Attach a copy of you Photo ID
To whom the PHI is be to disclosed:

Athens Spine Center
830 King Avenue
Athens, GA 30606

(p) 706-425-2400
(f) 706-395-3021
This authorization will expire: Six (6) months from the date signed below.

I understand that when my PHI is disclosed pursuant to this Authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing, except (i) to the extent that the Entityhas acted in reliance upon this Authorization; or (ii) to the extent that the Authorization was obtained as a condition of obtaining insurance coverage, there is other law that grants the insurer the right to contest a claim under the policy. I understand that my revocation must be submitted in writing to the Entity listed above stating that I wish to revoke this Authorization.
Signature*

Clear
Name of Patient or Personal Representative [If signed by a Personal Representative, please state such person's authority to act for the individual]: *

First NameLast NameRelationship to Patient
Date Signed*

MonthDayYear
Should be Empty:

Medical Records Request Form