Records Request Form

AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION

423 N. 21st. St., Ste. 100, Camp Hill, PA 17011 Ph# 717-761-0930 Fax# 717-441-1480 4387 Sturbridge Dr., Harrisburg, PA 17110 Ph# 717-761-0930 Fax# 717-441-4171
Use this form to allow another medical office/hospital/provider to send your medical records TO our practice, Jackson Siegelbaum Gastroenterology.
Patient's Full Legal Name*
Best Phone# to Reach Patient*
Please enter a valid phone number.
Patients Date of Birth*

MonthDayYear
Enter your Date of Birth

I hereby give my authorization to the provider or healthcare facility noted below to release information to Jackson Siegelbaum Gastroenterology regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis, or prognosis, including x-rays, correspondence, and/or medical records including those from my other health care providers that my provider / healthcare facility may hold, by means of mail, fax, or other electronic methods.*
Enter the name of your provider or healthcare facility
Enter your CURRENT PROVIDER's fax number here. We will send your completed request to this fax number, to request your records.*
Please enter a valid fax number for your providers Medical Record Request Team.
This authorization is for the following medical records. Please choose ONLY the medical records that you are requesting.*

Last office visitColonoscopy (including pathology)GI ImagingEGD (including pathology)Labs (within past 6 months)Liver Biopsy (report + pathology)Other (Specify Below)
My preferred location at Jackson Siegelbaum Gastroenterology is:*

NOTE: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions, or alcohol/ substance abuse have special rules that require specific authorization.

Please review the following five types of additional records. If you wish to issue consent for the release of the following types records, initial in the corresponding field.
Drug/Alcohol/Substance Abuse
Enter your initials here if you consent to the release of these records.
Psychiatric/Mental Health
Enter your initials here if you consent to the release of these records.
Genetic Information
Enter your initials here if you consent to the release of these records.
Tests for Antibodies to HIV
Enter your initials here if you consent to the release of these records.
HIV Diagnosis/Treatment
Enter your initials here if you consent to the release of these records.

The medical information/records are being requested for the following purpose:*

Update PCPRequesting a Second OpinionRequesting a Transfer of Care to New GIOther (Include explanation)

A photocopy or facsimile of this authorization shall be considered as effective and valid as the original.

I have been advised of my right to receive a copy of this authorization.
Patient’s Signature*
I am submitting this authorization on today's date:*

MonthDayYear
Select Today's Date
Should be Empty:

Use this form to allow another medical office/hospital/provider to send your medical records TO our practice, Jackson Siegelbaum Gastroenterology.