Permission to Release Records
HIPAA regulations require that we also have an executed Release of Information form prior to sending your records out. 
Please click on the GO button below to print a copy of the document.  This form requires Adobe Reader.  If you do not have that, clicking on the Adobe button will download a copy to your computer at no charge.  Once you have completed the form you may either fax it to us at :  678.736.7308 or attach a scanned copy to an e-mail addressed to: 
medrecords@cpg-atlanta.com
 

 
  NOTE: Information that is required is denoted by a red * next to the box.
  Name:
  *Required

  Patient Name:
 

  Email:
 

  Phone:
  *Required


  Date of Birth:                    *Required
                                            Please use MM/DD/YYYY format

  CPG Physician:                   Select a physician Dr. Farrell Braziel Dr. Jay Naik Dr. Jose-Maria Artadi Dr. Jose Villoncgo Dr. Natasha Thomas *Required

  CPG Therapist:                   Select a Therapist Lindsey Brown Sheridan Jackson Regina Ward Roy Dial *Required
 

  Reason for request/ Send Records to:  

  Date of last visit in our office:      

  Please remember to download the RELEASE of INFORMATION form - we cannot
  process your request without a signed copy of that form.