Gilbert Ghearing, M.D.

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MEDICAL RECORDS RELEASE FORM

Please be sure to sign, witness, and date the release for medical records before submitting it with your payment. Cost of medical records, in accordance with Tennessee Code Annotated 63-2-102, is $20.00 for the first 5 pages, .50 for each page after the 5th page, and may include the actual cost of mailing. 


You may bring it to the office before May 31 or mail it to Dr. Ghearing, P.O. Box 158, Celina, TN 38551.


Thank you.


NOTICE:
The medical practice of 
Gilbert Ghearing, M.D.,  in Celina, Tennessee, 

will be closing due to health reasons

and subsequent retirement.



To request your medical records,

please download the form below.



The mailing address is
P.O. Box 158, Celina, TN 38551.