MEDICAL RECORDS RELEASE
The following pages are forms necessary to
authorize the release of medical records.
One form authorizes the release of
records FROM Georgia Pain and Spine Care to another
organization, while the other form authorizes
the release of records from another
organization TO Georgia Pain and Spine Care.
Please fill out the appropriate form completely
and fax or deliver it to our office.
If you have any questions, please call our office
GEORGIA PAIN AND SPINE CARE
1665 Hwy 34 East, Suite 100
Newnan, GA 30265
T (770) 252‐7557
F (770) 252‐7513
Download Free Templates & Forms at Speedy Template http://www.SpeedyTemplate.com/
AUTHORIZATION TO RELEASE MEDICAL RECORDS
FROM GEORGIA PAIN AND SPINE CARE
authorize Georgia Pain and
Spine Care to release my medical records to the following person or organization:
Mail or Fax Records to:
Fax to Attn: