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Disclosure of Health Information

 

Copies of Your Medical Records

To request a copy of your medical record for yourself or a third party, print out and complete the Authorization for Disclosure of Protected Health Information Form (PDF).

Mail or fax the completed form to:

Need to have the authorization form mailed or faxed to you? Please call 814.863.1975.

PLEASE NOTE: Completion of the form in its entirety is required. Incomplete forms will be returned to you by mail for completion, delaying the release of your medical information. For example, dates must be entered in a mm/dd/yr format.

Fees

Fees apply to copies of medical records being released to employers, non-healthcare facilities, home addresses, or to insurance companies for application for coverage at the following rate:

Fees do not apply to copies of records being released to healthcare facilities or to insurance companies for settlement of a claim. Prepayment of $22.04 is required for Attorney/Subpoena, Insurance Co application, & District Attorney. For State Disability a prepayment of $27.92 is required.

Additional Information

If you have questions concerning whether or not charges will apply to your request, please call 814.863.1975.

If you have further questions regarding the release of information process, please call the Health Information Management Department at 814.863.1975.


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