Medical Release Form Penn Medicine
ADVERTISEMENT
1
2NAME
SEX
M
F
MR#
HUP
PPMC
PAH
AGE / DATE OF BIRTH
AUTHORIZATION FOR DISCLOSURE OF
ACCOUNT#
HEALTH INFORMATION
(PATIENT PLATE IMPRINT)
Patient Name (First, Middle, Last)
Date of Birth
Address
City/State/Zip Code
Telephone Number
Disclosed Information: (check all items to be released)
Entire Record
Abstract
Discharge Summary
Operative Report
Lab Reports
Radiology Images
Discharge Instructions
ER Record
EKG/ECG Tests
Medication Records
History and Physical
X-Ray Reports
Progress Notes
Physician Orders
Consultations
Other (please specify) _____________________________________________________________________________________
Covering the period(s) of care (list applicable dates of treatment) _____________________________________________________
Special Records:
I understand that information related to my diagnosis or treatment for AIDS/HIV, psychiatric care and treatment, treatment for drug
and alcohol abuse may be released as part of my health information. Please check appropriate box(es) below.
AIDS/HIV Information
Psychiatric Care/Treatment
Treatment for Drug or Alcohol use/abuse
Yes, disclose
Yes, disclose
Yes, disclose
No, do not disclose
No, do not disclose
No, do not disclose
Location of Services:
HUP
PAH
PPMC
Penn Home Care & Hospice Service (PHCHS)
CPUP/CCA Outpatient Practice(s): __________________________________________________ Other:___________________
Information To Be Provided To:
Name of Person or Institution
Address
City/State/Zip Code
Telephone Number
Purpose/Use Of The Requested Information:
Personal use by patient
Sharing with other health care providers
Other (please describe) ____________________________________________________________________________________
Format:
Paper Copy
Electronic Copy (provided on encrypted disk)
Authorization
I hereby authorize Penn Medicine to disclose the health information described above.
I understand that my authorization will automatically expire one hundred eighty (180) days after the date of signature on this form.
I understand that I may revoke this authorization at any time. I understand that to revoke this authorization, I must do so in writing.
I understand the revocation will not apply to information that has already been released in response to this authorization.
My refusal to sign this authorization will not affect my ability to receive treatment. By signing this form, I understand that I am
authorizing Penn Medicine to release information as described above.
Signature of Patient or Personal Representative
Print Name
Date
Relationship of Personal Representative to Patient
Date
If Authorization is signed by someone other than the patient, please state reason. _________________________________________
PLEASE READ INSTRUCTIONS ON REVERSE
*UPHS099*
DO NOT USE UNAPPROVED ABBREVIATIONS
*UPHS099*
Page 1 of 2
UPHS-099-1
AEL 6/2010
ADVERTISEMENT
1 votes
Related Articles
Related forms
Related Categories
Parent category: Legal