I hereby authorize Valdosta Family Medicine Associates, P.C ...

Valdosta Family Medicine Associates, P.C.

2412 N. Oak Street

Valdosta, GA 31602

Phone: 229-244-1400 / Fax: 229-244-5512

Authorization for Release of Medical Information

Print Name

Birthdate (MM/DD/YY)

Street Address

Phone (Cell)

City, State, and Zip

Phone (Home)

Social Security No.

Phone (Work)

Please check one:

ALL:

___ I hereby authorize Valdosta Family Medicine Associates, P.C. to release ALL

my medical records, including but not limited to, progress notes, operative

notes, laboratory results and diagnostic tests,including information related to

AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency

Virus), psychiatric care assesment, and treatment for alcohol and/or drug abuse.

ONLY: ___ Please include dates of service of records requested:

Records Released To:

Name:

Address:

Phone:

City, State:

Fax:

Zip Code:

Signature of Requestor or Parent/Legal Guardian for Minor (Under 18 years):

Signature (Full Name)

Date

Witness

Date

Is this a permanent transfer? (circle one)

Yes

No

Reason for transfering:

MEDICAL RECORDS ARE COPIED BY "Sharecare"

FEES ARE AS FOLLOWS:

01-20 pages: $0.93 per page

21-28 pages: $0.80 per page

29 & up: $0.20 per page

1-866-967-0133

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