Request Medical Records

Monday – Friday, 8:30am – 4:15pm
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)

If the record involves Radiation Therapy, please complete this form:

• Authorization to Release Protected Health Information (Radiation Therapy)

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:

Mailing Address Northeast Georgia Medical Center Release of Information 743 Spring Street NE Gainesville, GA  30501

Physical Address Northeast Georgia Medical Center Release of Information 3137 Frontage Road Gainesville, GA 30504

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.

Patients can 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 Help Desk
Call 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)

• Complete a Medical Record Change Request Form (Download)
  • Mail to: Health Information Management, 743 Spring Street NE, Gainesville, GA 30501

• 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..