Pennsylvania Medical Release Form 1Pennsylvania Medical Release Form 1
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NAME

SEX

M

F

MR#

HUP

PPMC

PAH

AGE / DATE OF BIRTH

AUTHORIZATION FOR DISCLOSURE OF
HEALTH INFORMATION

ACCOUNT#
(PATIENT PLATE IMPRINT)

Patient Name (First, Middle, Last)

Date of Birth

Address

City/State/Zip Code

Telephone Number

Disclosed Information: (check all items to be released) ❑ Entire Record ❑ Abstract
❑ Discharge Summary
❑ Operative Report
❑ Lab Reports
❑ Radiology Images
❑ Discharge Instructions
❑ ER Record
❑ EKG/ECG Tests
❑ Medication Records
❑ History and Physical
❑ X-Ray Reports
❑ Progress Notes
❑ Physician Orders
❑ Consultations
❑ Other (please specify) _____________________________________________________________________________________
Covering the period(s) of care (list applicable dates of treatment) _____________________________________________________
Special Records:
I understand that information related to my diagnosis or treatment for AIDS/HIV, psychiatric care and treatment, treatment for drug
and alcohol abuse may be released as part of my health