Medical Records & Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Health Information Management (HIM) / Medical Records
Authorization for Release
An authorization for release of confidential information is a written statement from the individual or the individual’s legal guardian; or in the case of a minor, the individual’s parent/legal guardian; who authorizes the disclosure of all or part of the medical record of the individual.
Authorization for Release of Your Medical Record
Requests for copies of your Dekalb Community Service Board medical records must be made in writing, must include your original signature, and must be hand-delivered, mailed, scanned or faxed to the Dekalb Community Service Board. You will need to complete the Dekalb Community Service Board Authorization to Release Protected Health Information (PHI) Form. If you are actively receiving treatment, your physician must sign to authorize the release for family involvement or personal use.
Authorization to Release Protected Health Information Form (PDF)
Completely fill out the form; date and sign; and mail or fax to the HIM/Medical Records Department. Proper identification will be required to pick up the records.
There is no charge for medical records that are delivered directly to another doctor’s office or medical care provider for continuation of care. There is a charge for records requested for personal reasons. The fee is $0.25 per page.
Phone: (404) 508-7714 Fax: (404) 508-7715
Office Hours: 8:15am to 5:00pm Monday thru Friday
Dekalb Community Service Board
Richardson Health Center
445 Winn Way, 4th Floor, Room 475
Decatur, GA 30030