Medical Release Form
This form allows Georgia Psychiatry & Sleep to request and/or release information to/from another entity.
On the next page you will see various blanks to input information.
The patient's information should be put in the first two(2) spaces ("Full Name" and "Date of Birth").
The entity's information to which Georgia Psychiatry & Sleep will be requesting and/or releasing information to/from should be input into the proceeding blanks ("Name", "Address", "Fax Number", and "Email Address").
Lastly, please provide directions for our office regarding the request. Directions such as which records you would like shared/requested, or any information we may need to complete the request.
All requests will need a valid fax number, as all records are requested or sent via secure fax. Without a valid fax number, we will not be able to complete the request. You may contact our office if you have any questions regarding this, before submitting the request.