Middle Georgia Medical Assoc PC - Medical Records Authorization
Patient Full Name (First, Middle, Last)
Please include your physical street address & mailing address if different (Street, P.O. Box, City, State & Zip)
I authorize and request a copy of my medical records / Protected Health Information (PHI) be released as follows:
Office Use Only
Middle Georgia Medical Assoc PC
623 South Houston Lake Rd, Suite 200
Warner Robins, GA 31088
PH: (478) 923-6633 FAX: (478) 250-9633
For office use only
Effective from the date of this authorization until such time my patient/physician relationship is terminated with the provider of care specified above, I authorize my Protected Health Information to be released to Middle Georgia Medical Assoc PC for the purpose of providing medical treatment, payment and/or healthcare options (TPO). This release or a photocopy thereof shall be valid as the original. I request a copy of my complete medical records be provided unless otherwise specified below:
OFFICE USE ONLY
The information or medical records to be covered by this release include test results for AIDS, HIV infection, Antibodies to HIV, or infection with any other probable causative agent of AIDS, and patient expressly authorizes their release pursuant to the Communicable Disease Prevention & Control Act, 81.103 of the
Health & Safety Code, VTCA. Check here _____ if the information or medical records to be covered by this release do not include those items set out in the preceding sentence
The information or medical records to be covered by this release include information or records pertaining to the diagnosis, evaluation or treatment of any medical or emotional condition or disorder, including alcoholism and/or drug addiction & patient waives the privilege of confidentiality accorded any information regarding diagnosis, evaluation & treatment or patient pursuant to VTCS art. 5561h. Check here _____ if the information or medical records to be covered by this release do not include those items set out in the preceding sentence.
In keeping with the compliance of HIPPA privacy policy with the regard to protected health information (PHI) this authorization shall remain in effect until such time my patient/doctor relationship is terminated with the provider of care of Middle Georgia Medical Assoc PC. I have been provided a copy of Middle Georgia Medical Assoc PC Privacy Policy. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to: Privacy Officer at Middle Georgia Medical Assoc PC, 623 South Houston Lake Rd., Suite 200, Warner Robins, GA 31088
Actual Original Patient Signature Required
