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 *
Date of Birth: *

Month Day Year
Date
INFORMATION TO BE RELEASESD

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 Notes Labs and Imaging Studies Billing Records
Other Instructions and Exclusions:
TIME FRAME OF RECORDS TO BE RELEASED *

MOST RECENT 3 MONTHS MOST RECENT 6 MONTHS MOST RECENT YEAR Other
Authorization
WHO IS COMPLETING THIS REQUEST? *

Patient Authorized Patient Representative
NAME OF PATIENT OF PATIENT REPRESENTATIVE *

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

Month Day Year
Date
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
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REQUEST AND AUTHORIZATION TO RELEASE MEDICAL RECORDS TO RESURGIA HEALTH SOLUTIONS

WHERE SHALL WE SEND THIS RECORDS REQUEST?

Patient Information

INFORMATION TO BE RELEASESD

Authorization