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Authorization to Release Medical Information

Instructions for Completion To our patients

Follow these instructions carefully when completing the authorization form. (Type or print neatly) The form must be entirely completed. Failure to do so could result in a delay to process this request to release your medical record information. Patient access fee may apply. Follow these steps:

  • Enter the patient name (maiden or former name, if applicable, full address, birth date and medical record number (if known) in the upper right corner of the form.
  • In the next section enter the name, address and telephone number of the hospital, doctor, company or person to whom the information will be released. The complete address must be included.
  • Check the box that best describes the purpose of your request.
  • List the time period related to the information you want released. If unsure of dates, use an approximate date with a question mark (?) to indicate questionable date range.
  • Next list the specific information you want us to release by checking the appropriate boxes or writing in the areas marked "Other". Be as specific as possible.
  • If patient had testing, diagnosis or treatment for any condition(s) as described under the SPECIAL AUTHORIZATION sections, it is required that the patient place their initials in front of the section(s) that describes the type of information to be released. Note: For patients between the age of 14 - 17 both the patient and parent or legal representative or guardian must initial, sign and date this form.
  • Under AUTHORIZATION SIGNATURES the patient, parent or legal/personal representative must date and sign the form. (Patient signs on first line; parent or patient representative signs on third line down and lists their relationship to the patient).

Note: If the individual signing the authorization form is a Guardian, Executor of the Estate or Power of Attorney for the patient, that person must submit a copy of the appropriate legal document, which proves authority to act on behalf of the patient. Relationship must also be specified. This must accompany the authorization form.

If the patient is deceased we need to have them write on the authorization Estate or No Estate. If there is no estate then we need the death certificate. The next of kin will need to sign the authorization. If there is an estate then we need a copy of the short certificate. The executor of the estate is the only one who can sign the authorization to receive records.

Click for the Authorization to Release Medical Information form (.pdf).

Mailing Instructions: The form cannot be processed unless it contains the required signatures and full date. Mail the completed form and any required legal documents to the Geisinger facility where your records to be released are located. Visit www.geisinger.org/locations for the listing of Geisinger community practice sites, or if sending to the hospitals, use one of the following addresses:

Please DO NOT ADDRESS TO Geisinger Health System - this is a registered trademark not a site or facility.

Geisinger Medical Center
Attn: Medical Reports
100 North Academy Ave.
Danville, Pa. 17822-1311
Phone: (570) 271-6319 (Option 1 + 5)
Fax: (570) 214-9523

or

Geisinger Wyoming Valley Medical Center
Attn: HIM Dept. - Medical Reports
1000 E. Mountain Drive
Wilkes-Barre, Pa. 18711
Phone: (570) 808-7822

Geisinger Bloomsburg Hospital
Attn: Release of Medical Information
549 Fair Street
Bloomsburg, PA 17815
Phone: (570) 387-2150
Fax: (570) 387-2456

or

Geisinger Wyoming Valley Medical Center
Attn: Release of Medical Information
1000 E. Mountain Drive
Wilkes-Barre, Pa. 18711
Phone: (570) 808-7822
Fax: (570) 808-6063

Geisinger Shamokin Area Community Hospital
Attn: Release of Medical Information
4200 Hospital Road
Coal Township, PA 17866
Phone: (570) 644-4200

PER HIPAA GUIDELINES, A COPY OF THIS FORM MUST BE RETAINED BY THE PATIENT.
Retain a copy
of completed form prior to mailing original to Geisinger.