HIPAA Authorization for Release of PHI

Company

This field is for validation purposes and should be left unchanged.

Patient Name*

Date of Birth*

Phone*

Provider Name*

Provider Address*

Provider Phone*

Provider Fax

Georgia Epilepsy & Neurology Institute, LLC

Address: 4275 Johns Creek Parkway, Suite C Suwanee, GA 30024

OR (If different recipient)

Name/Facility

Address*

Phone

Fax

3. Information To Be Released

Complete Medical Record/Office Visit Notes

EEG Reports

Imaging Reports (MRI, CT)

Lab Results

Medication List

Other

(Check all that apply)

Information To Be Released - Other*

4. Expiration

90 days from signature

1 year from signature

Upon completion of this request

Other Date

Expiration - Other Date*

Signature of Patient*

Signature Date*

If signed by Personal Representative:

Representative Name

Legal Authority (if applicable)

Relationship to Patient