Medical Release Form

Medical Release Form

Authorization to release information
Full Name *

Prefix First Name Last Name
Date of Birth *

Month Day Year
mm-dd-yyyy
I hereby request and authorize Georgia Psychiatry & Sleep to release and receive my medical records/information to:
Physician/Therapist name: *
Office address: *
Physician/Therapist fax number: *

Area Code Phone Number
Without a valid fax number, we are unable to process any medical record request.
Please provide instruction on whether to release/request and what records should be sent: *
Medical records frequently contain information which may be privileged and/or confidential remarks furnished by the patient, patient's family and staff. If, in the judgment of the medical staff, disclosure of the priviledged/confidential information will be harmful to the patient, release of such information may be withheld in accordance with specific state and federal regulations. Records released may contain alcohol and drug treatment information, AIDS/HIV, psychiatrics/psychological/other mental health privileged or confidential information. Certain communications are privileged and not subject to release without your consent under state and/or federal law.

After giving due consideration to the above statement, I authorize the Georgia Psychiatry & Sleep and/or members of its staff to furnish information, including matters privileged under the laws of the state of Georgia, and applicable federal laws and regulations, to the above organization, or to its agent. I further agree to indemnify and hold harmless Georgia Psychiatry & Sleep staff from all liability that may arise from the release of the information herein requested.
Patient Signature *

Clear
Date Signed *

Month Day Year
mm-dd-yyyy
Should be Empty: