Medical Release Form

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.

Medical Release Form

Authorization to release information
Patient's Full Name *

Prefix First Name Last Name
Patient's Date of Birth *

Month Day Year
mm-dd-yyyy
I hereby request and authorize Georgia Psychiatry & Sleep to * my medical records/information * :
Provider / Office Name: *
Name of who we are requesting/releasing to
Provider / Office Address:
Address of who we are requesting/releasing to
Provider / Office FAX Number: *

Area Code
Provider / Office PHONE Number:

Area Code
Provider / Office Email Address:
Not required.
Without a valid fax number, we are unable to process any medical record request. All records are sent via secure fax.
Please provide instruction on what records you would like to be shared or requested: *
Ex: All medical records, Lab results, etc
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 or Guardian Signature *

Clear
Patient or Guardian Name *

First Name Last Name
Date Signed *

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