Medical Records Release Request

Patient Information

Patient Name:

Contact Number:

Date of Birth:

Address:

City:

State:

Zip:

Email address

Social Security Number:

To From

Complete Women's Healthcare
634 Peachtree parkway Suite 110
Cumming, GA 30041

To From

Name:

Address:

City:

State:

Zip:

Fax:

Information to be obtained/Information to be released:

Complete Records

Labs

Last Exam(s)

Specific Date Range

Operative Reports)/Pathology Report

Patient Name

hereby authorize Complete Women's Healthcare to release my medical records as specified above. I understand that this information is protected under the Health Insurance Portability and Accountability Act (HIPAA) and cannot be released without my consent.

Note: Please allow 5 business days for processing. There is a $35 fee for the release of medical records to you directly in accordance with state laws.

**By signing below, I understand that (1) I release Complete Women's Helathcare and its employees, agents, officers and afficlaites from any and all liability, responsibility, claims and damage, which may results from the release of information authorized by this Consent for Release of Information; (2) This consent is valid from the date signed and continues until I revoke this authorization by giving Complete Women's Healthcare written notice; (3)I may revoke this authorization at any tie, unkless the afction has already been taken utilizing this signed consent or the authorization was obtained as a condition of obtaining insurance coverage; (4) The practice will not condition treatment or payment based on my signing this authorization; (5) I am signing this authorization freely; (6) NO one has pressured ime to sign this authorization; (7) I acknowledge that I've had the oppostunity to review this authorization and understand the intent use; (8) The information disclosed in this authorization may be subject to re-discosure by the practice and no longer protected by federal law.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of patient/Guardian

Date:

Your information will be encrypted.