Release of Information - St. Mary's Good Samaritan Hospital

As a patient, you are entitled to obtain copies of your medical records. Here are instructions and guidelines for submitting St. Mary’s Good Samaritan Hospital's authorization form for your paper records.

Please note we are able to release only those records that pertain to procedures or inpatient admissions at St. Mary’s Good Samaritan Hospital. We do not have records of visits to your physician or other healthcare providers.

To receive a hard copy of your medical records, please follow these steps:

  1. Please download and print the PDF release formAdobe Acrobat
  2. You must print legibly so we can easily find your requested records
  3. All sections must be completed for us to provide your records
  4. To receive copies of actual films and/or billing information, check the appropriate boxes on the form, as this information is not routinely provided with copies of the medical record.
  5. As provided by Georgia law, the charge to patients for copies of medical records is based on the number of pages processed. Patients are not charged when applying for Social Security or needing records sent to a physician for follow up care/change in physicians. The current Georgia Statute for fees is:
    • $0.97 per page for 1-20 pages
    • $0.83 per page for 21-100 pages
    • $0.66 per page for more than 100 pages

      If picking the records up in person you may pay the costs then, or if your records are mailed to you, you will receive a separate bill from Healthport.

  6. Please mail or fax the completed form to:

    St. Mary’s Health Care System, Inc.
    Health Information Management Department – Healthport
    5401 Lake Oconee Parkway
    Greensbor0, GA 30642
    FAX – 706.453.5086

  7. Please allow us 3-5 working days after we receive your request to prepare the records. Even though Georgia law gives us 30 days, we will make every effort to honor your time frame. We will call you when the records are ready.
  8. Once your request is prepared, you may pick up your records in person or we will mail them to you, whichever option you selected on the form; fax service is available only if you want your records sent to another health care provider. Records may be mailed out of town.
  9. If picking up records in person, please be prepared to present your photo ID. We can only give copies to the person designated to receive the records in the authorization.
  10. Our office hours are 8:00 a.m. to 4:30 p.m., every other Friday (please call to verify before visiting)
  11. If you are signing for another adult person, you will need to provide us with a copy of the patient’s Durable Power of Attorney for Health Care. In the State of Georgia, a general Power of Attorney does not cover release of medical records.
  12. If you are signing on behalf of the patient, you must identify your relationship to the patient at the bottom of the form and indicate your authority to sign. If there are any issues, our Release of Information office will give you a call. Parents may not request records for children age 18 or older without a valid Durable Power of Attorney for Health Care.

If you have additional questions, please call us at 706.453.7331.