Free Medical Release Form 27
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MEDICAL RECORDS RELEASE
FROM GEORGIA PAIN AND SPINE CARE
I, authorize Georgia Pain and Spine Care to release my medical records to the following person or
organization:
Mail or Fax Records to:
Street Address:
City: State: Zip:
Fax Number: Fax to Attn:
Please note: All Faxes must be sent with HIPPA Fax Cover Sheet.
I understand that this information will include any and all treatment plans, medication issues, history of
acquired immunodeficiency syndrome (AIDS), sexually transmitted diseases, human immunodeficiency
virus (HIV) infection, behavioral health service/psychiatric care and evaluations, treatment for alcohol
and/or drug abuse, or similar conditions.
The following information should not be released:
Patient's Name: Patient's Acct #:
SSN: DOB:
Patient's Signature: Date:
Witness: Date:
This form is valid for one year from patient signature date.