Medical Record Release Request

To release your medical records to a new provider, please print out this Medical Release form, fill it out completely, and mail it to the Planned Parenthood office where you have been seen (see list at bottom of page):

I, ___________________________________,(Patient’s Name)
______________,(SSN) ____________,  (Date of Birth)

hereby authorize the release of the following information
[] most recent exam and tests
[] all my medical records
[] sexually transmitted disease (“STD”) medical records (including but not
limited to laboratory results, treatment notes, reports or studies) in your possession to:
(Name of Institution/Provider)

(Address of Institution/Provider)

I understand that the records for care, treatment or medical services provided to me, and retained by you, may contain information regarding my STDs and sexual and drug use history. This information might further indicate my risk of contracting HIV. (HIV, or human immunodeficiency virus, is the virus that may cause or indicate AIDS of HIV infection.) Other HIV-related information, including testing for HIV, and HIV-related illnesses or AIDS, and the results of these tests may also be included in the records authorized for release.

I further understand that without this authorization, the provider would not be permitted to disclose this information, as indicated by law.

This disclosure of my medical records to ______________________________________
(Name of person receiving medical records)
is requested _____________________________________________________________.
(purpose of the disclosure)

I recognize that I may revoke this consent at any time except to the extent that the information has already been released in reliance of this form. If not revoked, this consent will expire one year from the date signed.

I agree further not to sue or hold the provider of the information, its employees or agents, responsible for any issues, claims or causes of action arising out of the release of information in conformance with the terms of this release.

_____________ ______________________________ ___________________
Date                     Patient signature                        Witness

 

NOTICE
TO: __________________________________________
(Name of Institution /Provider)

__________________________________________
(Address)

__________________________________________


Enclosed please find a copy of the medical records of ___________________________. These medical records are being disclosed to you from the records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is authorized by the confidentiality of HIV-Related Information Act. A general authorization is not sufficient for this purpose.



Very truly yours,
Planned Parenthood of the Susquehanna Valley