Medical Records Authorization (HIPAA) - Georgia

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — GEORGIA

This Authorization for Release of Protected Health Information (this "Authorization") is executed under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations at 45 C.F.R. Parts 160 and 164 (collectively, "HIPAA"), and, to the extent not preempted, the laws of the State of Georgia.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE INFORMATION

I authorize the following health-care provider(s), facility(ies), hospital(s), clinic(s), pharmacy(ies), laboratory(ies), and health plan(s) (each a "Provider" or "Covered Entity") to release my Protected Health Information ("PHI") as described below:

3. RECIPIENT(S) AUTHORIZED TO RECEIVE INFORMATION

4. SPECIFIC RECORDS AND DATE RANGE

Date range of records requested: From [__/__/____] to [__/__/____], or ☐ all dates of service.

Mark each record type to be released:

☐ All PHI in the patient's designated record set
☐ Office / progress notes and chart
☐ Hospital / facility records (admission, discharge summaries)
☐ History and physical / consultation reports
☐ Operative and procedure reports
☐ Laboratory and pathology results
☐ Diagnostic imaging reports and films (X-ray, MRI, CT, ultrasound)
☐ Emergency department / ambulance / EMS records
☐ Physical therapy / rehabilitation records
☐ Pharmacy and medication records
☐ Billing statements and itemized charges
☐ Records in electronic form, produced electronically (O.C.G.A. § 31-33-8)
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

The PHI is disclosed for the following purpose: [DESCRIBE — e.g., "evaluation and prosecution of the patient's personal-injury claim," "at the request of the patient," or "legal representation in Civil Action No. ____"].

6. HIPAA REQUIRED STATEMENTS (45 C.F.R. § 164.508(c))

6.1 Expiration. This Authorization expires on the earliest of: (a) [__/__/____]; (b) the event of [________________________________]; or (c) if no date or event is stated, the final resolution of the personal-injury matter described in Section 5, or two (2) years after the date of signature, whichever occurs first.

6.2 Right to Revoke. I may revoke this Authorization at any time by delivering a written revocation to the Provider's privacy officer at the address in Section 2. Revocation will not affect any action taken in reliance on this Authorization before the written revocation is received.

6.3 No Conditioning of Treatment. The Provider may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. PHI disclosed under this Authorization may be redisclosed by the recipient and may then no longer be protected by HIPAA or Georgia law. HIV/AIDS information, mental-health records, and 42 C.F.R. Part 2 substance-use records remain subject to the redisclosure restrictions noted in Section 7.

6.5 Copy of Authorization. I am entitled to a copy of this signed Authorization.

7. SPECIFICALLY PROTECTED CATEGORIES — SEPARATE AUTHORIZATION REQUIRED

I specifically authorize release of the following heightened-consent categories only where I have initialed:

HIV / AIDS Notice (O.C.G.A. § 24-12-21): AIDS confidential information may be disclosed only as authorized by the patient or as otherwise permitted by Georgia law; unauthorized disclosure is prohibited.

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

8. GEORGIA COPY-FEE AND RESPONSE-TIME NOTE

Under O.C.G.A. § 31-33-2, a provider must furnish the patient's records within 30 days of a valid written request. Under O.C.G.A. § 31-33-3, the party requesting records is responsible for copying and mailing costs, adjusted annually by the Georgia Department of Community Health. Effective July 1, 2025, the maximum rates are: up to $25.88 for search, retrieval, and other direct administrative costs; up to $9.70 per record certified; and for paper copies, $0.97 per page (pages 1-20), $0.83 per page (pages 21-100), and $0.66 per page (over 100 pages), plus actual postage and the full reasonable cost of reproducing non-paper records (e.g., radiology films). These charges do not apply to records requested to make or complete an application for a disability-benefits program. By statute (§ 31-33-3(c)), this fee schedule also applies to psychiatric, psychological, and other mental-health records.

9. SIGNATURE AND PERSONAL-REPRESENTATIVE AUTHORITY

I have read and understand this Authorization. I am the patient or the patient's authorized personal representative, and I sign voluntarily.

If signed by a personal representative:

10. NOTARY (OPTIONAL)

State of Georgia, County of [________________________________]

Subscribed and sworn to before me this [____] day of [____________], 20[____].

______________________________
Notary Public
My commission expires: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA Authorization core elements: https://www.ecfr.gov/current/title-45/section-164.508
• 45 C.F.R. § 164.524 — Individual right of access (fees, 30-day response): https://www.ecfr.gov/current/title-45/section-164.524
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• O.C.G.A. § 31-33-2 — Furnishing records on request (30 days): https://law.justia.com/codes/georgia/title-31/chapter-33/section-31-33-2/
• O.C.G.A. § 31-33-3 — Costs of copying and mailing: https://law.justia.com/codes/georgia/title-31/chapter-33/section-31-33-3/
• Georgia DCH — Medical Records Retrieval Rates (eff. July 1, 2025): https://dch.georgia.gov/medical-records-retrieval-rates
• O.C.G.A. § 37-3-166 — Confidentiality of mental-health clinical records: https://law.justia.com/codes/georgia/title-37/chapter-3/article-6/part-2/section-37-3-166/
• O.C.G.A. § 24-12-21 — Disclosure of AIDS confidential information: https://law.justia.com/codes/georgia/title-24/chapter-12/article-3/section-24-12-21/
• O.C.G.A. § 37-7-166 — Confidentiality of alcohol/drug treatment records