Release of Records Form

Click here to Download our Release of Records form

How do I fill out this form?

Once you download and print the form please fill out the sections highlighted sections but most importantly make sure to sign and date.  Our office will fill out what records specifically we are requesting.  

Please include at the top the name of that patient being seen by our group in the correct line if the records we are requesting are for a family member. 

If records are being requested on an individual over 18 years old, unless they are incapacitated, that person must sign the form.  

How do I return the form to?

You may either return by any of the follow methods

Fax:  423-610-1166 OR 423-246-4300
In-Person:  Johnson City office M-F, Kingsport office M-Thurs  

What is the purpose of this form?  

To obtain your consent to access you, your child's, or a family member's medical records in order to better care for you child.

Why might we need access to a parent or family member's records?

Children are often referred after a family member presents with a cardiac problem.  In order to better understand this it is helpful to review their medical records and see all testing results, espeically genetic testing.