MR 543 02 SPA Patient Authorization for Release of 2026

1. Click ‘Get Form’ to open the MR 543 02 SPA Patient Authorization for Release of in the 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 are requesting your medical records.
4. Specify the authorized employee or agent from Penn State Health who can discuss your healthcare information by filling in their name.
5. Indicate which specific medical information you want included in this disclosure by checking the relevant boxes.
6. Complete the 'Addressee Field' with the names and addresses of where to send or receive information.
7. Select your preferred format for receiving medical information from the options provided.
8. 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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