Medical Records Release Forms

October 24, 2016

Premier is happy to provide you with a copy of your medical records and/or x-ray/MRI images. However, we want you to know that there may be a charge for duplicating your medical records. The State of Tennessee regulates fees for copying records. Currently, the established fee for copies is $20.00 for the first five pages and $.50 for each additional page. The fee to copy workers’ compensation records is $10.00 for the first twenty pages and $.25 for each additional page. Postage fees apply for records sent by mail. There is no charge for faxing records to another physician as part of your continued medical care; however, you will need to complete a Medical Records Release form unless that physician is already on file as your primary care physician.

Please tell us if you need copies of your x-rays and/or MRI images. The fee for copying x-rays and/or MRI images to a compact disc (CD) is $5.00 per CD.

To protect your privacy, you MUST submit a signed Medical Release Authorizaton form (“HIPAA Patient Authorization Form”). For your convenience, you may download and print the form below. Please send the completed and signed authorization form by mail or fax. If you pick up your records in person, be prepared to show your photo ID.

To download the Medical Records Release Form, click here:
Medical Records Release Form

Our Medical Records Department will process your request in the order received, which may take up to ten days. If fees apply, a Medical Records Department Representative will contact you. For your convenience, we offer an option to pay over the telephone with a debit or credit card.

Medical Record Department Representatives:
Judy Bobbitt, Release of Information Department Manager
Telephone (615) 366-7002 or (615) 366-8890, ext. 1078
Fax (615) 366-2265
Email: jbobbitt@premier-ortho.com

Release of Information Specialists:
Julie Collier: serving Harding Place, and StoneCrest.
Telephone (615) 366-7015 or (615) 366-8890, ext. 1036
Fax (615) 366-2264
Email: jcollier@premier-ortho.com

Shannon Hunter: serving Centennial Care Center
Telephone (615) 366-7016 or (615) 366-8890, ext. 1045
Fax (615) 366-2428
Email: shunter@premier-ortho.com

Tonya Stout: serving Hendersonville, Skyline, and Summit Care Centers
Telephone (615) 366-7013 or (615) 366-8892, ext. 1079
Fax (615) 366-2423
Email: tstout@premier-ortho.com

Our Medical Records Department staff is dedicated to outstanding customer service. As such, they will make every effort to fulfill your request for records promptly. Please feel free to contact us if you have questions. Thank you.