Medical Record Request

MEDICAL RECORDS REQUEST
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
I hereby request the following information: *

Medical Records Billing Summary X-Ray CD Other
Which office are you primarily seen at?

Cumming Buford Duluth
I hereby authorize Academy Orthopedics, LLC to release medical records as indicated above and understand that records may include information regarding HIV, psychiatric and mental illness, drug/alcohol abuse records, venereal disease and any other statutory protected diseases.
Patient or Legal Guardian Signature *
Date

Month Day Year
Date

MEDICAL RECORDS REQUEST