Authorization for Release of Protected Health Information Form
Your medical history helps health care providers diagnose an injury or illness and determine the best treatment. They may send copies of your records to another provider or health plan only as needed for treatment, payment or with your permission. All medical records are protected under the laws of the state of Georgia and the HIPAA Privacy Rule.
Some individuals prefer to keep a personal copy of their medical records in case of rare instances when medical offices expunge inactive patient records, or if records are otherwise lost or destroyed. You have a right to inspect, review and receive a copy of your medical records and billing records held by health plans and providers. Click here to learn more about your rights regarding your medical records under HIPAA.
How to Request Medical Records
Adults over 18, legally appointed guardians, legally emancipated minors, and parents of a minor child may request medical records. To make a request, bring your current ID and an Authorization for Use or Disclosure of Health Information form to the Forest Park Annex. You can complete the form at the time of the request or print it out in advance.
- Search, Retrieval and Other
- Up to: $25.88
- Direct Administrative Costs
- Certification Fee: Up to $9.70/record
- Copying Costs for Records in Paper Form
- For pages 1-20: $0.97/page
- For pages 21-100: $0.83/page
- For pages over 100: $0.66/page
If you have any additional questions, please call 678.610.7199.