To request a copy of your Medical Record, please complete the downloadable HIPAA authorization form. 

After completing the form, submit it along with a clear copy of a valid state-issued photo ID using one of the available submission methods listed below. 

• Email Address: [email protected] 
• Fax number: 678-442-5839
• Mailing Address: 250 Scenic Hwy. Lawrenceville, Georgia 30046

Please note: E-signature Fonts are not acceptable.

SummitRidge Behavioral Hospital typically processes a Medical Record request within 30 business days of the date the Medical Record request has been received. Under HIPAA, we are required to respond within 30 days of the calendar, with the option of one additional 30-day extension if needed.

Yes. Applicable copying fees may apply. Under HIPAA, fees must be reasonable and cost based. In Georgia, additional fees may also apply for per-page copies and electronic records.

Once your request has been processed, an invoice will be generated for any applicable charges and sent to the address or contact information provided.

Only the individual or Legal Guardian authorized on the submitted HIPAA form may contact the Health Information Department regarding the request.

This helps protect the privacy and confidentiality of patient information. Individuals who are not listed on the HIPAA form will not be able to receive updates or discuss the status of the request.

The executor of the estate or distributee must complete the HIPAA form and upload a copy of the official death certificate and proof of their status as executor as supporting information.

Our contact number is 678-442-5883, and the hours of operation are from Monday to Friday from 9:00 am to 5:00 pm. Medical Record hours may vary based on the calendar holidays.