Release of Health Information
If you would like to request a copy of your health information, please complete the Authorization for Release, Use and Disclosure of Health Information form below.
Instructions for completing the Authorization for Release:
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Complete your personal information on top of page 1.
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Check the box - Access to Copy/Inspect
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Complete Section 1. This section should be completed if the information is being sent to an organization (doctor's office, another hospital, etc). This section does not have to be completed if the information is for personal use.
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Complete Section 2. Put in the date of service that you are requesting records for. Also check the appropriate box for the results and records that you are requesting.
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Complete Section 5. If you are the patient picking up your medical records, put your name. If you are the patient but wanting someone else to pick up your records, put the name of the person you are authorizing to pick up your records. Also make sure you check the appropriate boxes under Section 5 regarding purpose.
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Sign and date on page 2. Your ID is required when picking up medical records. If you are sending someone else to pick up your medical records, you will need to send a copy of your ID and this authorization.
Once you have the completed the Authorization for Release, you can fax it along with your picture ID to (912) 871-2388 and put to the ATTENTION of ANNA BELL.
Download the Authorization for Release, Use and Disclosure of Health Information form »
PLEASE NOTE: If your records are for anything other than your physician, there is a charge for your medical records. You can call Release of Information (912) 486-1851 for fees.
