HIPAA Notification of Privacy Policy

Fill out your form online or download a copy.

Medical Information Contact Form (HIPPA)

Medical Information Contact Form (HIPAA)

  • MM slash DD slash YYYY
  • Release of information:

  • Contact information:

    This contact information will remain in effect until terminated by patient/guardian in writing. I acknowledge that I have read and completed this HIPAA form that has been given to me by an office representative.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

Call The Office

(912) 489-1386
Fax: (912) 764-8533

Office Location

2 Lester Court
Statesboro, GA 30458
Located across from Statesboro High School.