Medical R ecords R elease A uthorization
Medi-Copy Services, Inc. / 210 12th Ave Sth #201 Nashville, TN 37203
Phone: (615) 780-2741 / Toll Free: 866-587-6274 / Fax: (615) 780-9866
1. I hereby authorize Tennessee Orthopaedic Alliance to release or disclose to the below-named person or organization all of my
medical records including any specially protected records such as those relating to psychological or psychiatric impairments, drug
abuse, alcoholism, sickle cell anemia, or HIV infection.
This office uses an outside copy service,Medi-Copy Services Inc, to copy its medical records. All copy fees comply with applicable
state law. Please make your check payable to Medi-Copy Services Inc, or by phone using your credit or debit card. Pursuant to
Tennessee State law, Medi-Copy Services Inc. requires payment to be made prior to the completion of your request.
2. PLEASE MARK ONE OF THE FOLLOWING
I wish to h ave co pies o f th e last 2 years o f my reco rds sen t directly to ano th er ph ys