Medical Records Release Forms

October 24, 2016
Hughston Clinic Orthopaedics Tennessee 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:

  • $5.00 Fee Non-refundable fee for search, retrieval and other     administrative costs at time of request.
  • Cost per page fee is based upon state of Tennessee guidelines and is due upon delivery of records:
    • $20.00 for pages 1 through 5 flat fee
    • $0.50 per page for pages 6 and over
  • TN Workers Comp records
    • $10.00 for pages 1 -20
    • $0.25 for each additional page
  • Xray Copies $20.00 per disk
  • Postage Actual Cost of postage (if applicable)
  • Certified Records $9.70 for each record certified (if applicable)

Please specify if you need copies of your x-rays and/or MRI images.

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.

Release of Information Specialists:

Misty

Telephone: 706-494-3374 or 1-800-331-2910    extension: Medical Records

Fax: 706-494-3042

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.