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.
Three Ways to Request Medical Records
Please note: it may take up to three days to process your request.
Visit your county’s health department to submit an Authorization for Use or Disclosure of Health Information form. You can complete this form at the time of the request or print it out in advance. We accept American Express, Discover, MasterCard, Visa, money order and cash.
Complete and send an Authorization for Use or Disclosure of Health Information form, a copy of photo ID and money order made payable to your county’s health department.
Print and complete an Authorization for Use or Disclosure of Health Information form and fax it to your county’s health department. Records cannot be returned to a personal fax and will be sent to the health department.
Complete medical record: $10.00
Copy of individual page or form (example: Immunization record): $7.00 (each)
If you have any additional questions, please call 1.800.847.4262