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.
- 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. This must accompany the authorization form.
Click for the Authorization to Release Medical Information form (.pdf).
Mailing Instructions: The form can not be processed unless it contains the required signatures and date. Mail the completed form and any required legal documents to the Geisinger facility where your records to be released are located. Click for the listing of Geisinger community practice sites, or if sending to the hospitals, use one of the following addresses:
Geisinger Medical Center
Geisinger Wyoming Valley Medical Center
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.