Medical Records Release Form Signature: Type or Draw × Type Mode On. Draw Mode On. Type It Draw It Clear Close Accept Signature. South Atlanta Neurology & Spine Clinic 518 Eagles Landing Pkwy Stockbridge GA, 30281 P- (770) 507-7359 F-(770) 507-8390 AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient’s Name:D.O.B:Previous Name:S.S.N: I request and authorize: PhoneFax to release health care information of the patient named above to: PhoneFax This request and authorization applies to health care information to include: All records Billing records Office notes (previous 2 years) Labs Radiology records (MRI’s, CT’s, X-rays, etc.) Other: Date From:to Expires:I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. Yes No I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. Yes No Patient Signature:Date THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED UNLESS OTHERWISE STATED.