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
Mail or Fax Records to:
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 #:
Patient's Signature: Date:
This form is valid for one year from patient signature date.