Records Release Authority (Incoming)

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Date of Birth:

Please complete this field.

Patient Street Address:

Please complete this field.

City/State/Zip:

Please complete this field.

Phone:

Please enter a 10-digit phone number (numbers only).

I authorize the use or disclosure of the above-named individual’s health information as described below.

The following individual or organization is authorized to make the disclosure.

Name of Facility/Dr. Releasing Records:

Please complete this field.

Fax #:

Please enter a 10-digit phone number (numbers only).

Phone #:

Please enter a 10-digit phone number (numbers only).

The type and amount of information to be used or disclosed is as follows:

DESCRIPTION OF RECORDS BEING REQUESTED: The applicable dates of service or treatment period→

Entire Medical Record

Radiology/Imaging

Labs

Clinic Notes

Abstract Medical Record

Pathology Report

Operative Notes

Other

Please complete this field.

I, the patient (or person authorized to consent for the patient), hereby request that you release to:

ATHENS OBSTETERICS & GYNECOLOLOGY

658 N. Chase Street, Suite 301
Athens, GA 30601
FAX: 706-548-9181

I understand this authorization includes the release of all medical records including Human Immunodeficiency virus records, Psychiatric, Drug/Alcohol abuse records, Venereal Disease, and any other statutory protected diseases. This authorization and consent will expire ninety (90) days following the date signed. I understand that I may revoke this authorization and consent at any time except to the extent that action has been previously taken in reliance hereof.

Please sign your name in the area below

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.

Date:

Please complete this field.

Subscribe to updates from Athens OBGYN