Line 1: Patient full name; date of birth; and medical record number (we can fill in the M.R.# if the patient does not know it.
Line 2: Complete address to include city, state and zip code.
Line 3: Phone number; social security #; dates of treatment to release; the boxes must be checked either “all” and/or “specify dates”.
Line 4: Name of person or organization records are to be released; phone number of same.
Line 5: “Full” address, including city, state and zip code.
Next section has two boxes, release to and received from. These must be checked.
Next is a list of documents in the chart. Patient must check either yes or no to the documents authorized to be sent.
“Do not draw a continuous line down the items.”
“For the purpose” must be completed.
Patient must sign full legal name, no initials and date the consent form.
Consent must be witnessed with full name, no initials and also date.
If any section is not filled in, not signed or witnessed the consent form will be returned to be completed, delaying processing patient’s request.
Upon completion, please return the form with original signature to:
Attn: Medical Records
5448 Yorktowne Drive
Atlanta, GA 30349