Fillable Online Piedmont Hospital Fax Email Print - DocHub 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your Student Name in the designated field. Ensure that you print your name clearly for accurate identification.
  3. Next, provide your signature in the appropriate section. This confirms your agreement to adhere to the guidelines established by Piedmont Healthcare.
  4. Fill in the Date field with the current date when you are signing the document.
  5. Complete the School Name and Piedmont Facility fields with the relevant information pertaining to your educational institution and placement location.
  6. Lastly, have your Faculty Name printed and ensure they sign and date where indicated, confirming their acknowledgment of your participation.

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Submit your signed and COMPLETED Medical Record Release of Information Authorization to the above address, email it to FairOaks@rrsmedical.com , or fax it to (540) 404-8081. Authorization.
Submit your signed and COMPLETED Medical Record Release of Information Authorization to the above address, email it to FairOaks@rrsmedical.com , or fax it to (540) 404-8081. Authorization.
Business hours are 8 a.m. to 4:30 p.m., Monday through Friday, and closed on Holidays. HIM fax number is 803-985-4684. Piedmont Medical Center contracts with CIOX, to handle the release of medical information. How can I get a copy of my medical records?
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For those, please print and complete the medical records form and fax it to our Health Information Management Department at 706-475-6961. For more information about Piedmont Athens Regional medical records, call 706-475-3361.
For those, please print and complete the medical records form and fax it to our Health Information Management Department at 706-475-6961. For more information about Piedmont Athens Regional medical records, call 706-475-3361.
In Person: Visit your countys health department to submit an Authorization for Use or Disclosure of Health Information form. You can complete this form at the time of the request or print it out in advance. We accept American Express, Discover, MasterCard, Visa, money order and cash.
For more information about programs and services offered at Piedmont Cartersville or The Hope Center, call MedLine at (800) 242-5662 or visit .cartersvillemedical.com.

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