(770)436-9700














(770)436-9700
 

  
     
  Medical Records
CPG is more than happy to provide medical records as needed to your insurance company, another medical provider, or anyone else you feel should have them.  However assembling these records can be a cumbersome task that demands precious administrative time. In addition, when necessary we use a bonded copy service resulting in a charge to this office. Therefore, we must charge a base fee of $50 to produce these documents.

To pay that fee online now please click below:		  
   
 		  
 

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:                   *Required

  CPG Therapist:                   *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.