Authorization for Release of Records

Instructions for Completing the Authorization for Disclosure of Health Information

1. Please carefully read and complete all sections of the Authorization for Disclosure of Health Information.

2. The patient or legally authorized representative must sign and date the form. Generally, only a patient may authorize release of his/her medical information.

   Exceptions to the rule are as follows:

   1. Authorization of minors - If the patient is a minor (under 18 years of age), the authorization must be signed by a parent or legal guardian.
   2. Emancipated minors - An emancipated minor is one who is or has been married, is or has been pregnant or who is a high school graduate. Emancipated minors can authorize the release of their medical information.
   3. A minor who has been diagnosed with a venereal disease, a substance abuse problem or was treated to determine pregnancy may consent to treatment of that disease or condition and may authorize release of any medical information related to that disease or condition.
   4. Authorization after death - An authorization must be signed by decedent's estate, or in the absence of an executor, the next of kin can authorize the release of medical information.
   5. Authorization of the incompetent patient - If the patient is deemed incompetent, then the patient's legally authorized representative must sign the authorization for release of information.
   6. Signature of Staff - The staff obtaining signature requirement applies only to the release of behavioral health care information as specifically authorized by the patient. The hospital or records management staff person obtaining this authorization of the patient or legally authorized representative (either in writing as witnessed, or by verbal confirmation of the written form) should sign, print name, date and time the form. A second witness is required to sign if the patient/patient representative consents verbally. Please have the witness sign, print their name and include the date and time.

Penn Medicine reserves the right to request proof of representation.

Any Ambulatory/Office Visit requests should be addressed to the individual Physicians Office.

The address to submit Inpatient, Emergency Department and Ambulatory Procedure/Short Procedure Unit record requests:

• Hospital of the University of Pennsylvania (HUP) - 3400 Spruce Street, Medical Records Department, 1st Floor Founders, Philadelphia, PA 19104
• Penn Presbyterian Medical Center (PPMC) - 51 North 39th Street, Medical Records Department, Myrin Basement, Philadelphia, PA 19104
• Pennsylvania Hospital (PAH) - 800 Spruce Street, Medical Records Department, 1st Floor Preston, Philadelphia, PA 19107
• Chester County Hospital (CCH) - 701 E. Marshall Street, Medical Records Department, West Chester, PA 19380
• Lancaster General Hospital (LGH) - 555 N. Duke Street, 1st Floor, Medical Records Department, Lancaster, PA 17604
• Penn Medicine Princeton Health (PMPH) - One Plainsboro Road, Medical Records Department, Plainsboro, NJ 08536
• Penn Medicine Doylestown Health (PMDH) - 595 West State Street, Medical Records Department, Doylestown, PA 18901

Please note:

1. Penn Medicine will charge for copying records in accordance with Pennsylvania, New Jersey and Delaware law, as applicable. Patient cost for Radiology images and reports will be free of charge.
2. Penn Medicine will not send medical information by facsimile unless the information is needed for patient care and delay in the transmission of the information would compromise patient care.
3. Penn Medicine will make reasonable efforts to comply with this request within thirty (30) days for information that is maintained or accessible on site and within sixty (60) days for information that is not maintained on site. If Penn Medicine is unable to comply with this request within the specified time periods, it may extend the applicable deadline for up to thirty (30) days by notifying you in writing.
4. Penn Medicine may deny this request under limited circumstances as provided for under federal law. Penn Medicine will notify you if it denies your request to access or obtain a copy of the requested information. If Penn Medicine denies this request, you may have the right to have a denial of your request reviewed by a licensed health care professional. To request such a review, please contact the Penn Medicine Chief Privacy Officer at the following address: Office of Audit, Compliance and Privacy, 3819 Chestnut Street, Suite 214, Philadelphia, PA 19104.
5. Records released may contain information and images created and prepared by third parties not under the control of Penn Medicine. Penn Medicine is not responsible for the content, accuracy or review of such records.
6. Recipients of mental health or HIV/AIDS information may not re-disclose that information unless with written patient consent or as allowed by law. Federal regulation 42 CFR Part 2 prohibits unauthorized disclosure of substance use disorder records.