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How to use or fill out PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL - Penn State Health with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'PATIENT INFORMATION' section. Enter your name, date of birth, medical record number, phone number, and email address. Ensure all details are accurate for proper identification.
- In the 'REASON FOR REQUEST' section, select the appropriate option that describes why you need your medical records. This helps clarify the purpose of your request.
- Next, authorize a specific employee or agent from The Milton S. Hershey Medical Center to discuss your healthcare information by filling in their name and selecting the type of information you wish to share.
- Complete the 'ADDRESSEE FIELD' with the name and address of the person or entity receiving your medical records.
- Choose your preferred format for receiving or releasing medical information in the 'FORMAT' section. Options include paper records, CDs, or online access.
- Specify which types of medical records you are requesting by checking relevant boxes and listing dates of service in the 'MEDICAL INFORMATION OR IMAGES BEING REQUESTED' section.
- Finally, sign and date the form at the bottom. If someone else is signing on your behalf, indicate their relationship to you.
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