MR 543 02 Patient Authorization for - Penn State Health 2026

1. Click ‘Get Form’ to open the MR 543 02 Patient Authorization 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.
3. In the 'Reason for Request' section, select the appropriate option that describes why you need to release your medical information.
4. Specify the authorized employee or agent from Penn State Health who can discuss your healthcare information by filling in their name.
5. Indicate what type of medical information you wish to be disclosed by checking the relevant boxes in the 'Medical Information or Images Being Requested' section.
6. Complete the 'Addressee Field' with details of where to send or receive information, including names and addresses.
7. Finally, sign and date the form at the bottom. If someone else is signing on your behalf, include their relationship to you.

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