MEDICAL RECORDS REQUEST
To
(Doctor/Hospital)
Address
City
State
Zip Code
Phone #
Fax #
I hereby authorize the release of my Medical Records or copies of such and request that they be transferred to:
Legacy Obstetrics & Gynecology
4229 Snapfinger Woods Dr.
Suite A
Decatur, GA 30035
Phone: 404-288-0746
Fax: 404-288-0925
Patient
(Print Name)
SS #
Date of Birth
From
To
(Date of Records)
Patients Signature
Date
Date Faxed
Date Mailed