Medical Records Request


Polaris Medical Group is more than happy to provide medical records as needed to your insurance company, another medical provider, or anyone else you feel should have them.  However assembling these records can be a cumbersome task that demands precious administrative time. In addition, when necessary we use a bonded copy service resulting in a charge to this office. Therefore, we must charge a base fee of $25 to produce these documents.  If your records exceed 5 pages you will be charged an additional $.82 per page. 

To pay the base fee online now please click below:
 

Permission to Release Records

HIPAA regulations require that we also have an executed Release of Information form prior to sending your records out.
Please click on the DOWNLOAD button below to print a copy of the document.  This form requires Adobe Reader.  If you do not have that, clicking on the Adobe button will download a copy to your computer at no charge.  Once you have completed the form you may either fax it to us at:  (404)766-8106 or attach a scanned copy to an e-mail addressed to: info@drlisaperry.com

  


  NOTE:
  Information that is required is denoted by a red * next to the box.
  Name:
  *Required

  Patient Name:
 

  Email:
 

  Phone:
  *Required


  Date of Birth:           *Required
                                   Please use MM/DD/YYYY format

  Physician:                 *Required
 

  Reason for request/ Send Records to:    

  Date of last visit in our office:      

  Please remember to download the RELEASE of INFORMATION form -
  we cannot process your request without a signed copy of that form.

 
 
 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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