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Authorization for release of medical records Penn State Milton S* Hershey Medical Center Health Information Services Mail Code HU24 P. O. Box 850 Hershey PA 17033-0850 Name of Patient Date of Birth Phone THIS AUTHORIZATION WILL NOT BE ACCEPTED UNLESS ALL ITEMS ARE COMPLETED. The information being disclosed may include HIV/AIDS Drug/Alcohol Abuse Mental Health data* This document authorizes release of information entered into my medical record prior to or within 12 months after the date of my si ...

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (160 Votes)

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What is authorization and release form?

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.

How do you write a release of information form?

How to Write a Release of Information Form? The Title. ... Information About the Party Who Is Consenting to Release Information (the Provider of the Consent). ... Information About the Party Who Is Receiving the Consent (the Receiver of the Consent). ... The Consent to Release Information. ... The Effective Date of the Release.

What is release authorization?

By setting up a Release Authorization (ARI), you are giving customer service your permission to disclose information about your accounts to another person. Typically, this is used to give account access to a spouse or other family member.

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