Hipaa Authorization Form For Release Of Medical Record Information printable pdf download

HIPAA Authorization Form for Release of Medical Record Information

In the State of Pennsylvania, the physician who creates the patient’s medical records is the owner of

those records. Current Pennsylvania Law states that a PHOTOCOPY of the medical record may be

released to the patient or the patient’s representative upon proper request within a reasonable period

of time. “Proper Request” means a request in writing, and the form below may be used for that

purpose. Please note that the law allows the physician a “Reasonable Period of Time” to comply with

your request. It also permits the office to charge a Reasonable Fee for preparing the copy.

Patient Name______________________________________ Date of Birth___________

Address________________________ City________________ State_____ Zip________

Telephone______________________ (Parent’s work or cell phone_________________)

I hereby authorize Lancaster Pediatric Associates, LTD. to use or disclose the protected health information for the above named

patient as described below.

The following person, physician, group or entity may receive disclosure of protected health information for

the above named patient:

Name and complete address

__________________________________________

Dates of Service

_____ Most recent two (2) years

_____ Specific dates of service ____________________________

Unless you sign here, NO information about alcohol/substance abuse, HIV/AIDS or mental health issues, including ADD and

ADHD, will be disclosed. *One signature required here*

(ANY PATIENT AGE 14 AND OVER MUST PROVIDE THE SIGNATURE HERE)

YES, disclose this information_________________________________________

NO, do NOT disclose this information___________________________________

I understand that the information used or disclosed may be subject to re-disclosure by the person or facility receiving it and then would

no longer be protected by federal privacy regulations.

I may revoke this authorization by notifying Lancaster Pediatric Associates, LTD. in writing of my desire to revoke. However, I

understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those

actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of the above

named patient on whether or not I sign the authorization.

My purpose for/intended use of this information is _______________________________

This authorization will expire in one (1) year after the date on this request.

FEES FOR COPIES: FEDERAL AND STATE LAW PERMITS A FEE TO BE CHARGED FOR

THE COPYING OF PATIENT RECORDS. LANCASTER PEDIATRIC ASSOCIATES, LTD. HAS

CONTRACTED WITH HEALTH PORT TO MAKE COPIES. HEALTH PORT WILL SEND AN

INVOICE WHICH CAN BE PAID BY CHECK OR PAID ONLINE AT

IF YOU HAVE ANY FURTHER QUESTIONS, YOU MAY

CONTACT HEALTH PORT AT (800) 464-0035. (FEE SCHEDULE ON REVERSE SIDE.)

____________________________ _____________________

__________________

Signature of patient if 18 years of age or older

Date

SSN or Date of Birth

__________________________________________

________________________________

___________________________

Signature of patent or guardian for minor child

Date

Relationship or authority

Is there a custody issue with this child?

Yes________

No________

Initial________

What is your current insurance:__________________________________________________________________________________

*One signature required here*

*This form must be fully completed before signing and requires signature in two (2) places.*

Hipaa Authorization Form For Release Of Medical Record Information

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