Authorization Procedure for Medical Information Release or Transfer

We are under strict Federal HIPAA compliance guidelines that dictate how we handle and share patient’s medical information. If you are requesting release or transfer of protected health information to third parties, you need to follow the procedures outlined below.

Patient Authorization Form for Practice to Release or Transfer Protected Health Information to Third Parties (Medical Record Release Transfer Request)

Instructions for Completion:

1. You must state specifically what information you are requesting to be transferred or released. Examples:
   1. Medical summary, growth chart, complete immunization history
   2. Complete medical record without restrictions
2. Complete the name and address of the party to whom the records are to be sent.
3. If you want to specify a time frame for the authorization, please enter a date in the field. If this section is left blank, the authorization will expire one year from the date of the form.
4. Complete the entire section of the form with signature, relationship to patient, patient name, Date Of Birth, date of signature and your name.

You may fax this information to Medical Records Coordinator, at 770-772-6099, or you can mail to our office at 3400A Old Milton Pkwy, Suite 330, Alpharetta, GA 30005.

There is a charge for production of medical records which is based on the size of the record. When sending this information, please include a contact number so that we can follow up with you.