Release of Medical Records TO Resurgia

REQUEST AND AUTHORIZATION TO RELEASE MEDICAL RECORDS TO RESURGIA HEALTH SOLUTIONS
I hereby request and give my permission for the provider or hospital listed below to release my medical records to Resurgia Health Solutions so they can better understand my medical history and provide medical care.

Please securely transmit my medical records to Resurgia Health Solutions using any of the options below:
- Via secure email to records@resurgia.com or,
- By Fax to (404) 445-5173 or,
- By Mail to:
  - Resurgia Health Solutions
    1100 Peachtree Street NE,
    STE 200,
    Atlanta Ga 30309
Please contact Resurgia Health Solutions at (404) 445-5304, X-6, OR at records@resurgia.com with any questions.
WHERE SHALL WE SEND THIS RECORDS REQUEST?

WHO ARE YOU ASKING TO SEND RECORDS TO RESURGIA HEALTH SOLUTIONS?
PERSON/ENTITY WITH RECORDS TO BE SENT TO RESURGIA HEALTH SOLUTIONS*
SUBMIT A NEW REQUEST FOR EACH PROVIDER
ADDRESS*
PHONE NUMBER*
FAX NUMBER *
Patient Information
PATIENT NAME*
RESURGIA MEDICAL CHART ID*
Your Medical Records Number should be available on your statement or on your patient portal.
Date of Birth:*

MonthDayYear
INFORMATION TO BE RELEASED

TO REDUCE THE ADMINISTRATIVE BURDEN OF PRODUCING RECORDS, PLEASE LIMIT YOUR REQUEST TO ITEMS AND DATES THAT ARE NECESSARY TO GUIDE YOUR CARE.
RECORDS TO BE SENT TO RESURGIA HEALTH SOLUTIONS*

Encounter NotesLabs and Imaging StudiesBilling Records
Other Instructions and Exclusions:
TIME FRAME OF RECORDS TO BE RELEASED*

MOST RECENT 3 MONTHSMOST RECENT 6 MONTHSMOST RECENT YEAROther
Authorization
WHO IS COMPLETING THIS REQUEST?*

PatientAuthorized Patient Representative
NAME OF PATIENT OR PATIENT REPRESENTATIVE*

First NameLast Name
RELATIONSHIP TO PATIENT (IF NOT THE PATIENT)
DATE OF REQUEST:*

MonthDayYear
SIGNATURE:*

Clear
Resurgia Health Solutions | www.Resurgia.com

Primary Medical Care at Home 1-84House-Doc | Phone: (404) 445-5304 | Fax: (404) 445-5173

1100 Peachtree Street NE, STE 200, Atlanta GA 30309
Should be Empty:

REQUEST AND AUTHORIZATION TO RELEASE MEDICAL RECORDS TO RESURGIA HEALTH SOLUTIONS

WHERE SHALL WE SEND THIS RECORDS REQUEST?

Patient Information

INFORMATION TO BE RELEASED

Authorization