Authorization to release medical record information

Instructions for completion

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.

Click for the Authorization to Release Medical Information form.

Follow these steps to complete the form:

  • 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 range with a question mark (?) to indicate questionable date range.
  • Next, list the specific information you want released 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 ages 14 - 17, both the patient and parent, legal representative or guardian must initial, sign and date this form.
  • Under the AUTHORIZATION SIGNATURES section, 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. The relationship must also be specified. This documentation must accompany the authorization form.

If the patient is deceased, the executor of the estate must write on the authorization form "Estate" or "No Estate." If there is no estate, the death certificate must be submitted. The next of kin will need to sign the authorization. If there is an estate, a copy of the short certificate must be submitted. The executor of the estate is the only one who can sign the authorization to receive records.

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

Mailing instructions: The form cannot 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. Address to the name of the facility where your records are located, and do not address to "Geisinger Health System." Visit www.geisinger.org/FAL to search for the appropriate facility. If sending to the hospitals, use one of the following addresses:

Request your medical records

Complete this form in full and mail to your host medical facility - addresses may be viewed below.  

Geisinger Medical Center
Attn: Release of Medical Information
100 N. Academy Ave.
Danville, PA 17822-1311
570-271-6319 (Option 1 + 5)
Fax: 570-214-9523

Geisinger Bloomsburg Hospital
Attn: Release of Medical Information
549 Fair St.
Bloomsburg, PA 17815
570-271-6319
Fax: 570-214-9523

Geisinger Shamokin Area Community Hospital
Attn: Release of Medical Information
4200 Hospital Rd.
Coal Township, PA 17866
570-644-4200

Geisinger Viewmont Medical
Attn: Release of Medical Information
435 Scranton Carbondale Highway
Scranton, PA 15508
570-207-5487

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

Geisinger Community Medical Center
Attn: Release of Medical Information
1800 Mulberry St.
Scranton, PA 18510
570-703-8155
Fax: 570-703-7266

Geisinger Lewistown Hospital
400 Highland Ave., 4th Floor
Lewistown, PA 17044
717-242-7252
Fax: 717-242-7544