Peachtree Orthopedics Medical Records Request Form

Form

*If patient is unable to sign, a copy of the legal documentation for patient’s representative must be supplied with a copy of this form.

Patient Identification

Patient Name:

Street Address:

City, State and Zip Code

Date of Birth:

Telephone Number

Email Address:

I request my records be provided:

Email Address Confirmation:

(Patients Only)

Peachtree Orthopedics Facilities (Select)

Information is to be Released to:

Name/Facility:

Attention:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Purpose of Request:

Information to be Released (If you fail to specify, a 1-year abstract of records will be provided)

From (date)

To (date)

Please select the type of information to be released:

Please select all that apply.

Other:

* If information requested is not on list above

If requesting Radiology (films), please select the Imaging Center Location:

Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release:

I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS Information.

If you do not agree type No here:

Time Limit and Right to Revoke Authorization

Except to the extent that action has already been taken in reliance on this Authorization, you have the right to revoke this Authorization by submitting a notice in writing to the Department of Health Information Systems or other Department to whom you are authorizing disclosure. Unless revoked, this Authorization will expire in 90 days from date of signature.

Confirmation

*Please confirm that you have carefully filled out this form in its entirety. If incomplete, we may not be able to fulfill the request.

Authority to Sign - if not patient:

Date:

Identity Verification Required

A copy of the patient's drivers license or other valid documentation (such as patient release documentation, letter of representation, etc.) is required for processing.

File Upload

. Only PDF, PNG, and JPG file types are accepted.

Create Signature

Search Lookup Values

Confirmation