Counseling and Psychiatry of Gwinnett, LLC goes to great lengths to ensure the privacy of our patients medical records. Your privacy is our top priority. We require our form signed in the office or with original notarized signature for ALL medical record release requests. We do not accept releases from other companies or faxed releases. An administrative fee of $50.00 is charges for medical record requests to patients, attorneys, insurance underwriting companies, and/or other requestors. We do not charge for transfer of records directly to another physician or medical office. We ask that you give us up to 30 days to complete medical record requests after a complete request and payment has been received.
- Patient Authorization to Release Medical Information Form*
- Patient Authorization to Release Administrative Information Only* – for patients who want to allow others to make appointments, pick-up prescriptions, or discuss billing issues. This does not allow release of any treatment or medical information.
*All areas on release forms must be complete and legible. Release forms not signed in office must be mailed with notarized signature.