Request Medical Records

Holiday hours may vary

Please print and complete the form below:

• Authorization to Release Protected Health Information (English)
• Authorization to Release Protected Health Information (Spanish)

This form is in .PDF format and will require the Acrobat Reader plug-in to view.

Then mail, deliver in person, or fax the completed form:

Fax:  770-219-6903

Please Note:

• We will be unable to process incomplete forms
• When mailing the form, please include a copy of your photo identification/driver’s license.
• Please also ensure that you include your telephone number in the event we have any questions regarding your request.

Starting on October 1st, 2017, patients will be able to access certain records using their MyChart account. Patients will need to create an account if they do not already have an active account, which requires a unique validation code. If you need help accessing MyChart or do not have a validation code, contact: MyChart Support HelpDesk:1-855 208-0122 or 770-219-1963(Monday through Friday 8:00 a.m. – 4:30 p.m.)

• Access Authorization to an Adult MyChart Record (English)
• Access Authorization to an Adult MyChart Record (Spanish)
• Access Authorization to a Minor’s MyChart Record (English)
• Access Authorization to a Minor’s MyChart Record (Spanish)

• Request Changes to your Medical Record
• Children’s Records:  Before your child’s medical records can be released, the legal guardian must complete, date and sign a release of information authorization.  If the child is over the age of 18, he/she must request the information himself.
• Mode of Release:  Medical records can be faxed only to a physician’s office, hospital, or clinic.  There is no charge for this service.  If you are requesting records be sent to yourself or any place other than those listed above, there are fees associated with production of records. 
• You may make an appointment to pick up copies of the record from our office during normal business hours.  Records can only be picked up with proper photo identification.  Otherwise, records will be mailed.
• Associated Fees:  Please see the Fee Schedule Acknowledgement form attached to the authorization form (above) to see the most current fee requirements based on Georgia regulations..