Retrieval For Medical Records Hughston Clinic printable pdf download

Retrieval For Medical Records Hughston Clinic

Attention Patients:

Please Read the following before signing the

attached release form.

Fax Number-706-494-3041

The Hughston Clinic Medical Records Department handles all record requests. For

questions about your bill for the record request or to check the status of the request please

call Hughston Clinic and ask for the Medical Records department at 706-494-3374 or

1-800-331-2910.

The fees are as follows:

• $5.00 Deposit

A Non-refundable deposit for search, retrieval and other

administrative costs is due at time of the request.

• Cost per page fee is based upon state of Georgia guidelines and is due upon

delivery of records:

$0.97 per page for pages 1 through 20

$0.83 per page for pages 21 through100

$0.66 per page for each page copied in excess of 100 pages

• Xray Copies

$20.00 per disk

• Postage

Actual Cost of postage (if applicable)

• Certified Records

$9.70 for each record certified (if applicable)

Please make sure that you are very specific when filling out the request for medical

records and state exactly what type of medical records you need.

Thank you for taking the time to read this important messages concerning the records that

you requesting.

Please sign and date this form so that the Medical Records Department acknowledges

that you (the patient) have read and understand the above information.

_________________________

_______________

Signature of Patient or legal representative

Date

Retrieval For Medical Records Hughston Clinic