Medical Records Release Authorization
Name:_________________________________________
Address:_______________________________________
________________________________________
_________________________________________
I hereby authorize and request you to release to:
Athens Primary Care
700 Sunset Dr, St 101
Athens, GA 30606
(706) 548-6068/ Fax: (706) 354-1218
my complete medical history and records in your possession concerning my illness and/or treatment during
the period from __________________to______________________.
Patient Name:_______________________________________DOB:_________________
(please print)
Address ______________________________________________________________
_______________________________________________________________
I am aware that some of the health care information or other information contained in the requested medical
records may be confidential or privileged and I hereby specified waive any privilege or confidentiality existing
under federal or state law regarding such information, but not limited to, protection afforded to:
1. AIDS Confidential Information
2. Medical Information Concerning Alcohol and Drug Abuse/Dependency
3. Medical Information
4. Medical Information Regarding Mental Illness
5. Communications Made to Psychiatrist/Licensed Applied Psychologist
6. Medical Information Concerning Mental Retardation
This authorization and consent is subject to revocation at any time, except to the extent that action has
already been taken in reliance on it.
Signature:_____________________________________Date:____________________
Witness:______________________________________Title:____________________
NOTE TO RECIPIENT:
The information that has been disclosed to you is or may be protected by state and federal law. You are
prohibited from making any further disclosure of this information unless further authorization is obtained or
disclosure is otherwise permitted by law. A general authorization for release of information may not be
sufficient.
This information requested was released to:________________________________________
On____________________________________by:__________________________________
Name:_________________________________________
Address:_______________________________________
________________________________________
_________________________________________
I hereby authorize and request you to release to:
Athens Primary Care
700 Sunset Dr, St 101
Athens, GA 30606
(706) 548-6068/ Fax: (706) 354-1218
my complete medical history and records in your possession concerning my illness and/or treatment during
the period from __________________to______________________.
Patient Name:_______________________________________DOB:_________________
(please print)
Address ______________________________________________________________
_______________________________________________________________
I am aware that some of the health care information or other information contained in the requested medical
records may be confidential or privileged and I hereby specified waive any privilege or confidentiality existing
under federal or state law regarding such information, but not limited to, protection afforded to:
1. AIDS Confidential Information
2. Medical Information Concerning Alcohol and Drug Abuse/Dependency
3. Medical Information
4. Medical Information Regarding Mental Illness
5. Communications Made to Psychiatrist/Licensed Applied Psychologist
6. Medical Information Concerning Mental Retardation
This authorization and consent is subject to revocation at any time, except to the extent that action has
already been taken in reliance on it.
Signature:_____________________________________Date:____________________
Witness:______________________________________Title:____________________
NOTE TO RECIPIENT:
The information that has been disclosed to you is or may be protected by state and federal law. You are
prohibited from making any further disclosure of this information unless further authorization is obtained or
disclosure is otherwise permitted by law. A general authorization for release of information may not be
sufficient.
This information requested was released to:________________________________________
On____________________________________by:__________________________________
