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Pennsylvania Medical Records Release Form

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This form is provided by Diagnostic Cardiology Associates, P.A. to authorize the disclosure or release of one person's protected health information.

Pennsylvania Medical Records Release Form
Pennsylvania Medical Records Release Form
DIAGNOSTIC CARDIOLOGY ASSOCIATES, P.A.
Patient Medical Records Release Form
Patient Name ________________________________________________________________ Date of Birth ____________________
Address ____________________________________________________________________________________________________
___________________________________________________________________________________________________________
Phone Number _________________________________________ Social Security Number _________________________________
I hereby authorize Diagnostic Cardiology Associates, P.A. to release/request the following information contained in my medical
records.
This is a ___ One-Time Disclosure ___ Continuous Disclosure for 12 months beginning _______________________________
All PHI including confidential All PHI except confidential selected below*
(*Note: While specific Confidential PHI will not be included, the information authorized for release may make reference to confidential findings.)
___ Lab Reports ___ X-ray Reports
___ Sexual Abuse Information ___ Sexually Transmitted Diseases (STD)
___ Drug and Alcohol Abuse Information ___ Child Abuse and Neglect
___ Psychiatric Information ___ AIDS / HIV
___ Other (please specify) ______________________________________________________________________________
Release of PHI is for: ___ Attorney ___ Physician ___ Insurance
___ Other (please specify) ___________________________________________________________________
Mail to (Name and Address): ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I understand that I may revoke this authorization in writing at any time, except to the extent that the release has been made prior to
my revocation in reliance on this authorization and that such release shall not constitute a breach of my right to confidentiality.
unless I otherwise revoke this authorization in writing it shall expire on the following date, event, or condition: _________________
___________________________________________________________________________________________________________.
At that time no express revocation shall be needed to terminate my authorization. I hereby release Diagnostic Cardiology Associates,
P.A. from any legal responsibility or liability for disclosures that may arise as result of the use of the information contained in the
PHI released.
I acknowledge that I have read this authorization and fully understand its contents.
Signed: ______________________________________________________________________ _________________________
Patient, Parent or legal Representative Date
Witness: _____________________________________________________________________ _________________________
Date
Employee Name: ______________________________________________________________ Date Received: ____________
*Treatment or payment may not be conditioned on obtaining authorization for release of PHI.
**Patient should understand that by releasing PHI, the patients PHI might be subject to re-disclosure.
***Employee receiving this revocation must fill out the following information and then place the signed original in the designated
place in the patient’s chart under the Authorization tab.
___ Mail records ___ Pick up records ___ Telephone for instructions _______________________________________________
Pennsylvania Medical Records Release Form