Return To: Northeast Georgia Medical Center, Inc. Health Information Management 743 Spring Street, NE Gainesville, Georgia 30501 (770) 219-0500 Fax (770) 219-6903 Authorization for Release of Confidential Medical Information Medical services provided by Northeast Georgia Medical Center are not condition upon this authorization Patient Name Date of Birth Patient Phone Number Treatment / Exam dates to be released Type of Visit: o Inpatient o Out Patient surgery This information is to be released to: o ER S.S. # o Out Patient Test Name o Therapy o Other: Attn: Purpose of disclosure (check one) o Insurance o Personal o Legal o Continuing Care o Other Specify Address City, State, Zip Phone Number Records will be faxed for urgent medical care only. Fax Number The information disclosed may be subject to re-disclosure by the recipient and will no longer be protected by the Privacy Protections. Portions of Record needed - Check applicable sections: o Entire Record o Visit History Only o Face Sheet o ER Record o Consultations o Consent Form (Condition of Treatment) o Therapy Records o Physician’s Progress Notes o Discharge Summary o Radiology Report o Physician’s Orders o History & Physical o Radiology Films/CD o HIV Testing / Information o Operative Report o Mammogram o Drug/Alcohol Test Results o Pathology Report o EKG o Other Radiology films, disks, and billing must be requested and picked up from the specific department. Output o Print o Online Port o Jump Drive I hereby authorize Northeast Georgia Medical Center and/or IOD to disclose/release medical records and/or other information obtained in the course of my diagnosis and/or treatment. I agree to pay copy charges if applicable for Legal, Insurance, and/or Personal Use. I hereby release Northeast Georgia Medical Center and/or IOD from any liability which may result from this disclosure of confidential medical information, or which may arise as a result of the use of the information contained in the information released. I understand that I may revoke this authorization by providing written notice of my intention. Unless withdrawn, this consent will expire in ninety (90) days from the date signed. o This information may include Medical/Surgical, Psychiatric, Substance Abuse, and HIV/AIDS information. o I authorize that this information may be faxed to the requesting Health Care Provider. Patient’s Signature Date Patient’s Representative Date Authority to sign on behalf of the patient is authorized by Witnessed By o Paid on site (Picture ID or the patient’s signature were used to verify identity) Paid by: o Card o Check o Send invoice Log ID # ________________ Please Note: Records requested for continued care will be mailed/faxed directly to the Doctor/Health Care Provider. Northeast Georgia Medical Center 0C-45 C-45 A A0 AUTHORIZATION FOR RELEASE OF INFORMATION FRONT NGMC FORM # C-45 A (10/10/14) Completed by: ___________ o Scanned PATIENT IDENTIFICATION: AUTHORIZATION FOR RELEASE OF INFORMATION Northeast Georgia Medical Center BACK FEE SCHEDULE ACKNOWLEDGEMENT FORM There are fees associated with Medical Record copies. This is governed by the Official Code of Georgia. Your medical records will be processed once the Authorization Form is completed along with this form, the Fee Schedule Acknowledment Form. You must fill out both forms completely before returning to us. Incomplete forms will not be processed. FEES $0.39 $0.36 $9.70 (Paper Records and Microfilm) per page for paper or jump drive per page for electronic portal delivery Certification Fee, if requested Payments accepted: (Please check how you want to pay): o Debit/Credit Card o Personal Check Patient Name (please PRINT): _____________________________________________ Signature of Patient or Representative: ______________________________________ Relationship to Patient: ___________________________________________________ Date Signed: ________________ NGMC FORM # C-45 A (10/10/14)