Medical Record Request Form

Medical Record Request Form
To request medical records, please follow the steps below:

1. Download the Medical Records Request Form
Ensure that you fill out the form completely.

2. Complete the Form
Make sure to provide all necessary details in the form. Incomplete forms
may cause delays in processing your request.

3. Sign the Form
Your request will not be processed without a signature. Please ensure the
form is signed before submiƫng.

4. Processing Time
Please allow up to 30 days for us to process your request and provide the
medical records. We will noƟfy you once the records are ready for release.
Patient Information

The following information is needed to assist the organization in locating the patient’s medical record.
Patients First and Last Name

First NameLast Name
Patients Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patients Date of Birth

MonthDayYear
Date
Patients Phone Number
Please enter a valid phone number.
If requesting on behalf of the patient
First and Last Name of Person/Facility name
Phone Number
Please enter a valid phone number.
Relationship to Patient
REQUEST Authorization: I hereby authorize the listed facility below to disclose records:

Red Top Wellness Center - Cartersville GANorth Georgia Recovery Center - Kennesaw GA
DISCLOSURE: Records to be disclosed to the person or entity listed below by:

Secure E-mailFax
Name of person or entity
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Purpose of Request:

Personal RecordsLegal RecordsContinuity of CareOther
- DESCRIPTION OF INFORMATION FOR RELEASE:
  o Entire Medical Record
  o Abstract of the Record*
  o Financial Record
  o Biopsychosocial Assessments
  o Psychiatric History and Assessment
  o History & Physical
  o Medical Progress Note
  o Medication List
  o Laboratory Test Result
  o Discharge summary
  
  **An abstract of the record includes the History/Physical Assessment, Biopsychosocial assessment,
  Treatment Plans, Discharge Summary**
  
  AUTHORIZATION FOR USE/DISCLOSEURE OF PREOTECTED HEALTH INFOMATION
  
  I understand that the information that I am authorizing to use/disclose may include information related to the diagnosis or treatment of mental illness, substance abuse, chemical dependency, and alcohol abuse, including privileged psychiatric or psychological communications and other detailed mental health information; infectious diseases, such as HIV/AIDS, tuberculosis or hepatitis.
  
  I hereby waive any privilege concerning such information for the disclosure to the person or entity I have authorized above. I understand that the information used/disclosed pursuant to this authorization will not include
  psychotherapy notes, which are notes recorded by a mental health professional documenting or analyzing contents of conversation during a counseling session that are kept separate from the rest of the medical record.
  
  I understand that unless otherwise limited by state or federal regulations, I may revoke this authorization at any time by presenting my revocation in writing to records@serenityhealthgrp.com
  
  I understand that this authorization is specific to the information, purpose and date(s) of services indicated above.
  
  I understand further that this authorization is valid for 90 days from today's date and will expire at that time.
  
  Note: There may be fees for provision of the information requested; however, records for treatment purposes may be faxed to the patient's healthcare provider when requested at no charge. Under most circumstances, applicable law permits up to thirty (30) days for record requests to be processed.
Patient or Legal Representative Signature:

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Medical Record Request Form

Patient Information

If requesting on behalf of the patient