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Medical Records Release (Outgoing)

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By signing this authorization, I authorize Athens OB/GYN to use and/ or disclose certain protected health information (PHI) about me to or for the party or parties listed below:

This authorization permits Athens OB/GYN to use or disclose to:

(name and address of Person or Entity to receive the information):

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VIA:

REASON FOR REQUEST:

REASON FOR REQUEST:

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Specific records to be disclosed:

Specific records to be disclosed:

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When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPPA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that Athens OB/GYN has acted in reliance upon this authorization. My written revocation must be submitted to Athens OB/GYN’s Privacy Officer at 658 N. Chase Street, suite 301, Athens, GA 30601.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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** There is a $25 fee for medical records and additional charges may apply**

** There is a $25 fee for medical records and additional charges may apply**