Dr. James K. Fortson - Medical Records Request

Medical Records
ENT Associates of South Atlanta is more than happy to provide medical records as needed to your insurance company, another medical provider, or anyone else you feel should have them. However assembling these records can be a cumbersome task that demands precious administrative time. In addition, when necessary we use a bonded copy service resulting in a charge to this office. Therefore, we must charge a base fee of $25 to produce these documents. Pages in excess of 5 are charged at $.82 per page

To pay that fee online now please click here:

Permission to Release Records

HIPAA regulations require that we also have an executed Release of Information form prior to sending your records out.
Please click on the GO button below to print a copy of the document. This form requires Adobe Reader. If you do not have that, clicking on the Adobe button will download a copy to your computer at no charge. Once you have completed the form you may either fax it to us at: (404)659-2273 or attach a scanned copy to an e-mail addressed to: office@fortsonent.com

NOTE:
Information that is required is denoted by a red * next to the box.
Name:
*Required

Patient Name:

Email:

Phone:
*Required

Date of Birth:           *Required
                                   Please use MM/DD/YYYY format

Physician:                 *Required

Reason for request/ Send Records to:

Date of last visit in our office:

Please remember to download the RELEASE of INFORMATION form - we cannot process your request without a signed copy of that form