Records Request Information Form

This records request form is to send your records by E-mail or receive information on how to obtain the records by other means. The person filling out this form assumes responsibility for the information to be factual and used for non-malicious intent.

Patient's Name*
First Last
**If the patient had a name change, please list the name used at the time of the exam.
Patient's Birthdate*
Month
Day
Year
Patient's Address*
Street Address Address Line 2 City State ZIP Code
Records Requested*
- Current valid prescription only - please allow 3-5 business days
- Copy of records from 3 years ago until present - expect 2-4wk arrival
- All records - may take up to 30-60 days for retrieval
- Other - please fill out request in Comments section below
Full records may take up to 60 days to send, and records beyond 10 years may not be retrievable. Photos or images may be subject to fees. **Please note that we cannot send expired prescriptions. Glasses have a 2-year expiration and contacts have a 1-year expiration** FEES FOR PAPER COPY OF RECORDS WILL BE INCURRED AND MUST BE PAID BEFORE THEY ARE PRINTED.
Name of person requesting the information*
First Last
If the patient is 18+ years old, consent must be noted in the patient's record that the person other than the patient requesting the information has access to the records.
Relationship to the patient*
Cell Phone Number of Person Requesting Information*
Email to send records or request further information*
Do you consent to send the record(s) by unsecured email?*
- Yes
- No
The information requested will be sent by a non-encrypted email. By checking yes, you have read or are familiar with the limits of privacy through non-encrypted email at www.hhs.gov. If you check "no", we can e-mail information on other means of obtaining the records.
Would you like a text confirmation that the record(s) were sent?*
- Yes
- No
Comments:
Signature*
PLEASE NOTE! If you do not get an email confirmation after pressing submit, please verify the email and resend or contact us.
Comments
This field is for validation purposes and should be left unchanged.

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770-343-5467 (Text Only)

Records Request Information Form

Douglasville Office Hours & Location

Menu

770-343-5467 (Text Only)

Douglasville Office Hours & Location

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