Home
About Us
What We Treat
Mental Health (Geriatric)
What to expect
Financial Arrangements
Accepted Insurances 2025
Medical Records
Employment
Contact
Select Page
Home
>
Medical Records
>
Authorization for Release of Health Information form
Authorization for Release of Health Information
I hereby authorize Berwick Hospital Center to release the following information from the medical records of:
Patient Information
First Name
*
Middle Initial
Last Name
*
Name at Time of Treatment (if different)
Date of Birth
Phone
*
Email (optional)
Street Address
City
State
Zip
I am requesting my records from:
Facility Name
*
Facility E-mail
Address
City
State
Zip
Facility Fax
What records do you want to receive or have disclosed to the recipient noted? (Check appropriate boxes below):
Date of Service:
Through
Progress Notes
Emergency Room Record
Discharge Summary
History and Physical
Consultation(s)
Lab Reports
Pathology Report
Operative Note(s)
lmaging/X-Ray Films
Imaging/X-Ray Reports
Entire Record
Fetal Heart Monitor Strips
Other (specify)
Other (specify)
*
If it exists, the following Sensitive Information can be disclosed:
Alcohol Abuse
Drug Abuse
Communicable diseases, including HIV status
Genetic Testing
Psychiatric/Behavioral Diagnoses
How would you like your records delivered?
Paper
Electronic
I will pick up in person
Mail to address below
If mailing, where do you want the information sent? (Fill in boxes below):
Please provide my records to:
Myself
Personal Representative (indicated below)
Other Third Party (indicated below)
Recipient Name
Recipient Phone
Recipient Fax
Recipient Mailing Address
*
Recipient E-mail (if applicable)
Please print your name and sign below:
Name of Patient or Personal Representative
Relationship
eSign of Patient or Legal Representative:
*
eSign Can not be empty
Clear Signature
Date of Signature:
Upload Identity Document
*
Send
