Medical Center Record
Resume:
AUTHORIZATION TO
RELEASE
MEDICAL INFORMATION
FEE MAY APPLY
Patient name:
Address:
City, State, Zip: Date of birth:
Medical record number:
Phone number:
A-560-008-DMR Rev./MRPC Approved 11/21
This form is used by all provider entities of the Geisinger Health (which is not a provider entity) including Geisinger Medical Center (all campuses), Geisinger Wyoming Valley Medical Center (all campuses), Geisinger Clinic (all sites), Geisinger Community Medical Center (all campuses), Geisinger Bloomsburg Hospital, Geisinger Lewistown Hospital,Geisinger Jersey Shore Hospital, Geisinger Medical Center Muncy, and all other provider entities as outlined in the Geisinger Notice of Privacy Practices but excluding Marworth, and Geisinger Community Health Services. I am requesting records from the following Geisinger entities:
All Sites Specific Clinic(s) or Hospital(s):
I authorize an appropriate workforce member of the above entity(ies) to release information from my medical record to: Name of hospital, company, or person to whom the information will be released to: Complete address:
Telephone number: Fax number: Email address:
*I am requesting that the information be produced (choose one): Paper copies Fax Download to Email CD
*For the purpose of: continuation of medical treatment payment of bill Worker’s Compensation education
legal purposes insurance purposes at the request of the patient or the patient’s legal representative
Other (specify):
*The information to be released will cover the time period from / / to / / . (“present” equals date of signature)
*SPECIFIC INFORMATION TO RELEASE:
Clinic Notes EEG, EKG, Stress Test Immunizations Pathology Reports
Colonoscopy Emergency Dept. Notes Laboratory Reports X-Ray Reports
Consultation Report(s) Endoscopy Medications X-Ray Films
Discharge Summary History & Physical Operative Report(s) Itemized Bills
Other (specify):
I understand that in order to process this request for the reproduction of medical record information on a timely basis, the above entity(ies) may utilize a contracted medical record copy service, and I further authorize the release of my medical record information to such record service for this purpose. I understand that this authorization is revocable by me, in writing, at any time, except to the extent that action has been taken in reliance on it. I will contact the Geisinger Privacy Office immediately at *******************@*********.*** or 570-***-**** if I wish to revoke this authorization. I also understand that this consent will expire six months after the date of signature or automatically when the records requested on this authorization have been released (which ever occurs first). I understand that the information released may be re-released by the recipient and may no longer be protected by HIPAA (Federal regulations). The above entity(ies) may not condition my treatment or payment for my treatment on obtaining this authorization from me, unless this authorization is requested (i) to provide research-related treatment to me, or (ii) because the health care being provided to me is solely for the purpose of creating protected health information for disclosure to a third party SPECIAL AUTHORIZATION (IF APPLICABLE)
Patient
initials
Parent/Guardian
initials
If you are authorizing the above entity(ies) to release information related to the testing, diagnosis and/or treatment for any of the following conditions, please sign your initials in front of the section which describes the type of information to be released.
(initials)
(initials)
My evaluation, testing, diagnosis or treatment for alcoholism and/or drug abuse or dependence may be released.
(initials)
(initials)
My evaluation, testing, diagnosis or treatment concerning my inpatient or outpatient mental health/rehabilitation treatment may be released.
(initials)
(initials)
My testing, diagnosis or treatment for HIV/AIDS may be released. AUTHORIZATION SIGNATURES
NOTE: IF PATIENT IS UNDER 14 YEARS OF AGE AND IS NOT AN EMANCIPATED MINOR THE PARENT OR GUARDIAN MUST SIGN. Date/Time: Patient Signature: Staff Signature:
If patient is unable to sign authorization form because of physical condition or age, complete the following: Patient is a minor or patient is unable to sign authorization because: Date/Time: Signature: Staff Signature:
(Parent/legal or personal representative)
If Verbal consent: Witness #1 Date/Time Signature: If Verbal consent: Witness #2 Date/Time Signature:
(Parent/legal or personal representative)
Description of personal representative’s authority to act for the patient:
***COPY OF COMPLETED AUTHORIZATION FORM MUST BE GIVEN TO PATIENT Geisinger Instructions to Complete the Authorization to Release Medical Information Form - A valid HIPAA authorization form requires the following information be documented on the form. Please note Pennsylvania Regulated Fees Apply regardless of format selected. Patients/Representatives: Carefully read and complete the Authorization to Release Medical Information Form if requesting patient medical information be sent to someone other than the patient or patient’s legal representative.
Patient Information: Please fill out blanks in the top right corner of the form. If you don’t know your medical record number, make sure patient birthdate and phone number is completed. Geisinger Entities: Please choose locations you are requesting. Authorized Recipient: Full name, complete address, phone number, fax number and email address, if applicable are required.
Select the Format: Please select the format of the information: Paper, Fax, Download to Email, or CD Purpose: Please select a purpose for this request. Time-Period: Please complete the time frame you are requesting. Specific Information to Release: If it applies to your request, place an “X” by the items you are requesting. If you are requesting “all” medical record information, please checkmark the box “Other” and specify “all.”
Specially Protected Health Information:
A valid HIPAA authorization form requires the patient or patient’s legal representative to initial if requesting specially protected health information and the medical record contains Alcohol/Substance Abuse, Mental Health and/or HIV/AIDS information.
Authorize: Please print your name, sign and date the form. If the patient lacks legal capacity, a legal representative may sign for the patient. Please see details below: Note:
If the individual signing and authorizing the release of medical information is a guardian, executor of the estate or power of attorney for the patient, a copy of the of the appropriate legal document which proves authority to act on behalf of the patient and their relationship must also be specified. This legal documentation must accompany the Authorization to Release Medical Information Request Form if it is not already scanned into the patient’s medical record. If the patient is deceased, the executor of the estate must write on the Patient Access Request Form "Estate" or "No Estate." If there is no estate, the death certificate must be submitted. The next of kin will need to sign the form. If there is an estate, a copy of the short certificate must be submitted. The executor of the estate is the only one who can sign the form to receive records. PER HIPAA GUIDELINES, A COPY OF THIS FORM MUST BE RETAINED BY THE PATIENT. Make a copy of your completed form prior to mailing the original to Geisinger. Contact Information:
Health Information Management (Medical Records) –
Geisinger System Release of Medical Information Department Call Center 570-***-****, select option 5 to speak with a release of medical information specialist for assistance.
Submit completed forms to Geisinger Centralized Release of Medical Information Department
Fax completed form(s) to one of the following fax numbers. 570-***-****
OR
Mail completed form for processing to:
Geisinger Medical Center
Attn: Release of Medical Information
100 North Academy Ave.
Danville, Pa. 17822-1311
or Geisinger Wyoming Valley Medical Center
Attn: Release of Medical Information
1000 E. Mountain Drive
Wilkes-Barre, Pa. 18711-3845
Primary Care Physician Records
May be requested directly from your care site.
Updated 01.13.2025
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