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 ________________________________ 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 __________________________________ 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.
____________________________ _____________________ __________________
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.*
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