Patient Forms

Authorization to Discuss/Share Medical Records/HIE Form

This form will allow a patient to designate another to obtain, read, discuss, view and overall deal with their medical records.

For example; a patient can sign these forms in order to allow Georgia Pain and Spine Care to discuss their medical records with their spouse, son, daughter, etc.

Authorization to Discuss or
Disclose Health Information

Adobe Acrobat document [391.7 KB]

Authorization to Release Records from Georgia Pain and Spine Care

This form will allow a patient of Georgia Pain and Spine Care to release their records from our facility to another.
For example; a patient moves out of state and is attempting to join a new pain management facility in their new state. The patient will print this form, fill it out, send it to Georgia Pain and Spine Care where we will release the appropriate records mentioned in the printout to the new facility of the patient’s choice.

Auth to Release Med. Rec.
to different Facility

Adobe Acrobat document [82.7 KB]

Authorization to Release Records to Georgia Pain and Spine Care

This form will allow a patient to have their current doctor’s office or another facility send their medical records to Georgia Pain and Spine Care.

For example; a patient is referred to our office for further care as a new patient. Georgia Pain and Spine Care requests records from the patient’s previous facility of care – the patient can print this form, fill it out and turn it into their previous facility allowing them to release appropriate records mentioned in the form to Georgia Pain and Spine Care.

Authorization to
Release Medical Records

Adobe Acrobat document [80.4 KB]

Physician’s Office Fax Referral Sheet

This form allows a doctor’s office to refer a patient to our care. The referral form can then be emailed or faxed to us once it is completed and filled out.

Fax Referral Sheet

Adobe Acrobat document [628.5 KB]