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Medical Records

  • Patient’s Name, Date of Birth, Address and Phone Number
  • Facility Authorized to Release Information to:
    • Records Released to you – write in “SELF”
    • Records Released to another Provider or Facility – please fill in the Providers name, address, phone and FAX number.
    • Health Information to be disclosed – include all dates of service, what type of records you want released (labs, x-ray, complete, etc.), why you need the information (treatment, insurance, personal)
  • Ensure the Sensitive Information section is understood and completed by checking “Yes” or “No”. Failure to make this selection may delay the release or result in a denial of the request.
  • Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
  • Leave the Witness Signature line and everything below it blank.

You will also need to include a legible copy of your driver’s license or your official ID so we may verify your signature with your hospital record.

Bring completed forms to the Medical Records department inside DeKalb Regional Medical Center.