• 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?
  • Patient Information

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  • 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.
  • Authorization

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  • 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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