Patient Forms
Authorization for Use and Disclosure of PHI to a Spouse or Other Individual
Use this form to grant access to your West Georgia Dermatology medical record to your spouse or any other individual(s) for purposes other than treatment, payment, or healthcare operations.
Prefer to handle it another way? Complete this form through the Patient Portal, or call (770) 838-9333 and our front desk will have a copy ready at your visit.