Patient Forms

New patient health history

As a new patient, it’s important for us to have information about your health history. Please complete this form and bring it with you to your appointment. This information will be entered into your personal health information file. This information is completely confidential and only used by your team of healthcare professionals.

Medical records

For you, as a patient, there are processes in place to allow you to review your medical records. Our Health Information Management team is available to assist you in obtaining a copy of your records. All patients can electronically download medical records by selecting the button below, or patients can request them from Harbin Clinic via the authorization form below.

Contact Health Information Management at 762.235.3660 on Monday – Friday, 8 AM – 5 PM, for more information.

Portions of your medical record may be available to you through a secure, online service called the Harbin Clinic Patient Portal. To sign up or learn more about visit the Patient Portal section of our website or ask a patient representative at your next visit to Harbin Clinic.

To electronically download your medical records, please click the link below

To request medical record information from Harbin Clinic, complete the form below

Download Authorization for the Release of Medical Records:


How do I give Harbin Clinic access to my other medical records?

You may need to authorize release of your medical records from your current doctor(s) before seeing a Harbin Clinic doctor.

To request information from other facilities

Download Patient Authorization To Obtain Outside Medical Records PDF:


Important steps

  1. Complete all fields on the authorization form(s) when requesting the release of your records.
  2. If you do not know your Harbin Clinic patient number, leave it blank.
  3. After the form(s) is signed and dated, fax the information to Health Information Management at 706.291.9782 or mail it to Heath Information Management at 221 Technology Parkway, Rome, GA, 30165.
  4. Typical processing time to request medical records is seven to 10 business days, depending on the availability of the medical record.