Authorization for Release of Health Information form

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I hereby authorize Berwick Hospital Center to release the following information from the medical records of:

Patient Information

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I am requesting my records from:

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)

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If it exists, the following Sensitive Information can be disclosed:

Alcohol Abuse Drug Abuse Communicable diseases, including HIV status Genetic Testing

Psychiatric/Behavioral Diagnoses

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How would you like your records delivered?

Paper Electronic I will pick up in person Mail to address below

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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)

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Please print your name and sign below:

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Click here for BHC HIPAA Authorization Instructions

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