Requesting Records from Cobb & Douglas Public Health

Medical records may be requested by any client who has been served by the Cobb & Douglas Public Health. There are specific requirements that must be present for records to be released. Due to Federal and State Privacy regulations, record requests are carefully reviewed prior to release. General rules are below:

• An Authorization of Disclosure must be completed for any request of records from the Cobb & Douglas Public Health. The authorization may either be from a physician's office or medical facility or you may use the PDF file from the Cobb & Douglas Public Health website to complete this request.
• For us to identify a patient and locate the appropriate record, we need to have the patient's name, including former names by which they may have been know and the patient's full date of birth. If these items do not match the information in our database, records will not be released. To protect the privacy of all our patients, we must be confident that we have the correct patient to release any records.
• The release must contain:
  • A specific and meaningful description of the information to be used or disclosed. You are required to explain what it is that you want disclosed from your record. Examples include "the entire record", "the last physical exam," "the last pap smear result."
  • The name or other specific identification of the persons authorized to make the requested use or disclosure. Identify who you are and what authority you have to make the request when you are not the person for which the records are being released. This includes the name of the person of who the records are being requested, as well as the signature and identification of the person requesting them. If it is you are requesting your own record(s), write SELF on the 'relationship to patient line.' As there are laws governing who can sign for release other than the patient, you may need to be required to show evidence of relationship.
  • The name or other specific identification of the persons to whom the covered entity may make the requested use or disclosure. The name of the agency, facility, physician or other healthcare practitioner to whom you want the record to go must be present. A full address and phone number are required to be complete.
  • A description of each purpose of the requested use or disclosure. This can be a written statement or a box checked on the form. Common purposes include: continuing medical care, transferring physicians, personal use, insurance purposes, etc.
  • An expiration date or expiration event that relates to the individual or the purpose of this disclosure. You have the right to say how long this release is effective, for example 6 months, 1 year.
  • Signature of the individual and date. (Or the individuals' personal representative) and date.
  • If the authorization is signed by a personal representative of the individual, a description of the representative's authority to act for the individual.
• We are required to ensure that the consent has been signed by the patient (or parent/guardian), therefore, we require that the signature of the same be witnessed and that witness also signs the consent with a date.
• Signatures will be compared to signatures on file. If they cannot be confirmed, the records will NOT be released.
• Georgia State law requires that certain types of medical information have special acknowledgement by the patient (parent/guardian) prior to release. There are five areas of privilege that require this special consent. These are:
  • Mental Health Information
  • HIV/AIDS Information
  • Substance Abuse Information
  • Sexually Transmitted Disease Information
  • Genetic Information
• Privileged and confidential medical information is governed by, but not limited to, the following O.C.G.A. Section 24-9-21, O.C.G.A. Section 24-9-40 (a), O.C.G.A. Section 24-9-47, O.C.G.A. Sections 37-3-166 (a) (8.1), 37-7-166 (a) (9); and 42 USCA 290dd-2; 42 CFR Part 2.

Please note: many physician offices do not have these areas of privilege on their consent. You may have to write it in or you can use the County form.

To obtain your own medical records from us there is a fee involved. These records cannot be mailed; you must pick them up at the site where your care was provided. This fee must be paid prior to receipt of records. In addition, there is a 48 hour turnaround time for records to be replicated once requested. There is no charge for records which are being sent to a healthcare provider or facility.

Prior to moving, we recommend that you obtain a copy of your child's immunization record.

The Request for Authorization for Disclosure can be faxed to the specific program where the records are located. If that number is not known or you are not sure which program, the request may be faxed to the Medical Records Department of Cobb & Douglas Public Health at (770) 794-4365. You may also mail the request to:

Disclosures

• Authorization For Disclosure Of Health Information
• Autorización Para Revelar Información Médica