G My decision to revoke the Authorization does not apply to any release of my records that may have taken place prior to the date of my revocation of the Authorization may be responsible for payment of the claim. g UPMC cannot require me to sign the Authorization in order to receive treatment. g In accordance with 4 Pa Code 255. 5 b Drug Alcohol treatment information to be released to judges probation or parole officers insurance company health or hospital plan or government officials shall...
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Video instructions and help with filling out and completing upmc release information form
Instructions and Help about Pittsburgh form

Hello Dave Guerra real record service how are you thank you for stopping by today to watch this video today I'm going to talk about the authorization to release health information form it's usually a one-page document I know another medical document you have to fill out but you know what this is for your own protection because again this lets the hospital the private practice or the clinic know what you need why you need it and who accessed it and who gave it to you the whole nine yards which is a good thing especially when your privacy is at stake so ideally I'm going to go over the farm from top to bottom and what I'm looking at or what you're gonna see is you show up at the medical records department at the clinic or the doctor's office you say hey I need a copy of my medical records well they're gonna hand you a form typically like I said one page now they might go into - it just depends on your location there might be your state might require additional notifications that's okay that's strictly up to them so but for the most parts I've encountered one-page documents and usually cram everything in there but please read the entire document before you fill it out again read the entire document before you start putting your name on that piece of paper now at the top of the form should say the practice the hospital or the clinic that's it has the information next there should be a title and bold letters will say authorization and disclose protected health information authorization to disclose medical records authorization to release protective wealthwise percent protected or health information or medical information again then the next section would be your name we're not necessarily your name the patient's name and that would be like the legal representative you would be the legal representative you would need to put the patient's name down there we go sorry about that and then you put the patient's full name not like Jake you actually put Jacob not Tony unless that's what it is in his birth certificate nats how they signed in you would put anthony otherwise the date of birth now you may be asked for additional information that's okay because again how many Jon semester in the world and how many John Smith's share the same birthday so again now you might be asked like I said for additional information this would typically be like your address or your social security number maybe like the last four digits or if you have a medical record number that's okay if you don't no problem between you and the medical record clerk you guys you will definitely drill down to get exactly your information the next section will be where you or the legal representative of the patient will authorize the facility the hospital the clinic the private practice and will be written on there or in some cases you have to fill it out yourself that's okay and you authorize them to disclose the information relating to the above-named individuals health information in this...