• Communicare Therapy Services

    6000 Shakerag Hill Ste 108, Peachtree City GA 30269
  • Email: admin@ct-speechtherapy.com

    Phone: (678)619-0178 Fax: (678)701-1139
  • Medical Records Release

    Medical Records Release

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  • By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information to the facility listed below:

    Communicare Therapy Services

    6000 Shakerag Hill Suite 108 Peachtree City, GA 30269

    Phone: 678-619-0178 Fax: 678-701-1139


  • Clear
  •  - -
    Pick a Date
  • Parent or Legally Authorized Representative

    In case the subject is beyond the legal age of consent:

  • Clear
  •  - -
    Pick a Date
  • Should be Empty: