Medical Records Release

Authorization for Release of Individually Identifiable Health Information

Holston Medical Group, PC, is dedicated to maintaining the privacy of your Protected Health Information (PHI), which is your individually identifiable health information (this may include such data as your name, address, phone number, date of birth, Social Security Number, account information, medical record number, or any other unique identifying number). In conducting our business, we will maintain records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. Holston Medical Group, PC, uses a contracted release of information vendor and fees are associated for copies of medical records unless sent to another healthcare facility as continuation of care.

Requested medical records will be billed at the rates listed below by our contracted release of information vendor.

  • Fifty cents ($0.50) per pages 1-40
  • Twenty-five cents ($.25) per page for each page copied after the first forty (40) pages
  • Sales tax and actual cost of mailing

Authorization Form

To request authorization for a release of information, please print this form, fill out and bring to an HMG office to begin the process:

HealthPort's Contact Information:

105 W. Stone Drive, Suite 5D
Kingsport, TN 37660

Telephone Number: (423) 378-7686
Fax Number: (423) 378-7687