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Health Information Management

Requests and Release of Information (1201)

As a patient, you have a federal right to get copies of most medical records, whether they are paper copies, or electronic health records. Doctor's notes, medical test results, lab reports and information must be supplied to patients that ask and Dodge County Hospital will do its best to make this as easy as possible for you.

Please read the following information to learn how to request your records.

The federal law that addresses medical record is called HIPAA, the Health Information Portability Accountability Act of 1996 Pub. L. 104-191.

Some results may be available through our Patient Portal
Third party requestors please see frequently asked questions for authorization submission process.

Request Medical Records

The medical records department is open Monday-Friday (closed on holidays), 8:00 A.M. - 4:30 P.M.

Helpline- (478) 448-4036
Fax- (478) 374-5266

To request records you must have some type of personal identification (driver's license)
To have a copy of your medical records sent to another medical facility, or physician, or to obtain a copy for personal reasons. Please complete the following steps:
1.) Download the Authorization for Release Of Protected Health form:Authorization of Release Form
2.) Print, complete, and acknowledge the Authorization Form in its entirety.
3.) Fax or mail the completed, signed Authorization Form and personal identification to the number above or address below.

Dodge County Hospital
Medical Records Department
P.O. Box 4309
Eastman, GA 31023

There will be no charge for having your medical records sent to another medical facility if faxed to the facility only. If you want to obtain copies for any personal reasons, you may be charged a minimal fee per page.

If there were multiple visits only fax one request, but ensure all requested dates of service are on the form.

Please ensure the authorization form is legible for verification of identity.

Dependent upon what and how many records you are requesting there could be a longer than expected turn around time.

LEARN ABOUT: Accessing Your Medical Records & Personal Health Information

Records for you Own Use
If you wish to obtain medical records for your personal use we are happy to assist you in this process. The per page charge is as follows:
Pages 1-20 .99 per page
Pages 21-100 .83 per page.
Greater than 100 .66 per page.
Sales tax, and postage as applicable, will be charged for medical records per Georgia Statue 45 CFR 164.524(c)(4) and O.C.G.A. 31-333.

Authorization for the Release of Protected Health Information Form

All requests for medical records must be fully completed and dated on or after the date of discharge to be processed. After the properly executed authorization has been received, our team will review for all required elements and processes in accordance with federal and state laws governing you privacy and medical records. Please allow 3 to 5 days for this process. For your convenience we offer delivery by fax, or records can be mailed to the address listed on the authorization.

Your Rights and Access to Personal Health Information

Dodge County Hospital recognizes the patient's right to access and obtain copies of their protected health information (PHI) in accordance to HIPAA laws. (Code of Federal Regulation 164) as well as Georgia Statutes. Should you require any behavioral health records, O.C.G.A. 31-33-2 requires physician approval prior to us releasing any medical records to you. Please allow an additional 3 to 4 business days for these requests to be processed.

Records for you Physician(s)

Dodge County Hospital can fax records to your physician's office at no charge to you, once you complete the authorization for the Release of Protected Health Information Form in detail ensuring the following items are included:

Physician Name
Complete Address
Phone Number
Fax Number
A form must be completed for each physician who may need your records mailed or faxed.

Insurance Requests/Attorney Requests/Disability Requests

Requests should be sent from insurance companies, attorney or Departments of Disability Determination Services and, mailed to the address or faxed to the number on our authorization. All charges for medical records will be billed to the requestor.

Radiology/Imaging Films/Discs

Please contact the radiology department directly to facilitate your request. (478) 448-4047.


Who may request medical records and who must share them?
To request medical records, you must be the patient, or the parent or guardian of the patient for whom you seek records. Caregivers or other people may be able to access records if the patient has provided written permission to the provider or a durable power of attorney.

The U.S. Department of Health and Human Services provides good background information for understanding who may have access to your records.

Providers are required to share with any other providers currently treating you with continuity of care if needed any notes or records they have created themselves, or any test results for which they have copies. They are also required to share any information provided to them about you by another doctor if that information was used for the diagnosis and/or treatment being discussed with you.

Diagnostic lab test records, for such tests as blood tests, CT scans, X-rays, mammograms or others, should be requested from the doctor who ordered them, or your primary care physician.

If you seek hospital records or records from any other medical facility besides Dodge County Hospital, you will want to request them directly from that facility.

Be aware that you may be denied some records, usually related to mental health records. If a provider believes that letting you look at your medical records can endanger your physical health, your request may be refused. They believe revealing the information to you might lead you to physically harming yourself, your request can be denied. If you are refused, the provider must make that clear, in writing.

How do I obtain copies of medical records for those other than myself?
My Child
The parent or legal guardian must sign the consent release. Legal guardians will be asked to provide documentation of legal guardianship.

Patients who are 18 or older, but unable to sign consent due to physical/mental illness
Durable Healthcare Power of Attorney (or other court appointed documentation) must be provided.

Patients who are deceased
The legally appointed Executer of Estate must complete the consent for release. If there is not an appointed Executor of Estate, the surviving spouse can consent for release. If there is no surviving spouse any surviving child can consent for release. If no surviving spouse of children, than any parent may consent for release.

Please complete Certification of Authority to Act of Behalf of Deceased for Disclosure of Medical Records (link)

Is there a fee for obtaining my medical records?
Fees for personal records are as follows:
Pages 1-20 .99 per page.
Pages 21-100 .83 per page.
Greater than 100 .66 per page.
Sales tax, and postage as applicable, will be charged for medical records per Georgia Statue 45 CFR 164.524(c)(4) and O.C.G.A. 31-333.

What if I am a third party and would like to request medical records?
To obtain a copy of a Dodge County hospital medical record, we require a written request and properly executed patient authorization for disclosure of protected health information. This can be mailed to Health Information Management, Release of Information Services, at the address of the hospital or faxed to (478) 374-5266.
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