Release of Medical Records TO Resurgia

AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO RESURGIA HEALTH SOLUTIONS
I hereby give my permission for my provider or hospital 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 at records@resurgia.com or via fax at (404) 445-5173.

Please contact Resurgia Health Solutions at (404) 445-5304 with any questions.
Person or Organization to Release Information

Who should we send this completed medical release to
Name of Entity or Person to Release Information *
Address
Phone and Fax Number
Patient Information
Name *
Date of Birth: *

Month Day Year
Date
Information to be Released
What records are to be released? *

All Medical Records Medical Records for Specific Dates
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Records to Release *

Encounter Notes Labs and Imaging Studies Billing Records
Other Instructions and Exclusions:
Authorization
Who is completing this request? *

Patient Authorized Patient Representative
Name of Patient or Representative *

First Name Last Name
Relationship to Patient (if not patient)
Date: *

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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AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO RESURGIA HEALTH SOLUTIONS