• Request to Access Patient Records  

    This form is HIPAA compliant and secure for submitting personal identification information. If you have any questions or concerns, please do not hesitate to contact the pharmacy directly (404) 815-1610.
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  • Information Request




  • Signature

    I understand that I am allowed to have access to these records and that the information will be provided to me in either hardcopy or electronic form.  I understand that this request does not apply to certain health information, including: (1) information that is not held in the designated record set; (2) information compiled in reasonable anticipation of or for litigation; and (3) other information not subject to the right to access information under HIPAA.
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