Request for Medical Records

Request Medical Records

Under the Health Insurance Portability and Accountability Act (HIPAA), you or your designated patient advocate have the right to obtain copies of your medical records. To help us serve you in a timely manner, please complete the following information.

Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Person Requesting Medical Records*
- Patient
- Parent/Guardian
- Authorized Caregiver
Name (if not patient)
First Last
Email Address*
Phone Number*

Schedule an Appointment

Summit Counseling Center

Main Office

2750 Old Alabama Rd
Suite 200
Johns Creek, GA 30022

(678) 893-5300
info@summitcounseling.org

Dunwoody Satellite Location

Dunwoody UMC
1548 Mt. Vernon Rd.
Dunwoody, GA 30338

Johns Creek Satellite Location

Johns Creek UMC
11180 Medlock Bridge Rd
Johns Creek, GA 30097

Milton Satellite Location

Bethany Bend Village
13680 Highway 9 North
Building G, Suite 500
Milton, GA 30004

Sugar Hill Satellite Location

Church On The Hill
4600 Nelson Brogdon Blvd
Sugar Hill, GA 30518

Summit School Locations