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, Ciox Health, 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.

Records delivered in paper

  • $0.97 release of information (ROI) vendor labor cost and page fee
  • $0.05 per page*

*The first two pages are free in VA and NC

Authorization Form

To request authorization for a release of information, please print this form and complete. You may either bring the completed form into an HMG office or fax it directly to our release of information vendor at (423) 378-7687, or mail it to the address below.

Records delivered by email

  • Electronic Format (CD/USB/Email via ROI Vendor Portal)
  • $6.50 flat fee

Authorization Form

To request authorization for a release of information, please print this form and complete. You may either bring the completed form into an HMG office or fax it directly to our release of information vendor at (423) 378-7687, or mail it to the address below.

Ciox Contact Information:

105 W. Stone Drive, 6th Floor
Kingsport, TN 37660

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