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 CSB medical records must be made in writing, must include your original signature, and must be hand-delivered, mailed, scanned or faxed to the DeKalb CSB. You will need to complete our 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. 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. Please note medical records can take up to three business days to receive.
The fees are listed below:
- 1-20 pages: $0.75/page
- 21-100 pages: $0.65/page
- 100 pages: $0.50/page
- Medical records pick up and processing is 8:30 am – 4:00pm Monday-Friday
- Office Phone Hours: 8:15am-5pm Monday-Friday
Phone: (404) 508-7714
Fax: (404) 508-7715
DeKalb Community Service Board
Richardson Health Center
445 Winn Way, 4th Floor, Room 475
Decatur, GA 30030
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