MR 543 02 Patient Authorization for Release of Medical Records 2026

1. Click ‘Get Form’ to open the MR 543 02 Patient Authorization for Release of Medical Records in our editor.
2. 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.
3. 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.
4. Next, authorize a specific employee or agent from Penn State Health to discuss your healthcare information by filling in their name and selecting the type of information you wish to share.
5. Complete the 'Addressee Field' by providing the names and addresses of where you want the information sent. This is crucial for ensuring your records reach the correct destination.
6. Choose your preferred format for receiving medical information in the 'Format' section. Options include paper records or digital formats like CDs or online access.
7. Specify which medical records you are requesting in detail under 'Medical Information or Images Being Requested.' Check relevant boxes and list dates of service as needed.
8. 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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