Consent to Release Information Form (PDF)
Please note a valid release must contain the following nine elements. We will not release records if you submit an incomplete form.
If you need assistance completing the form, please contact our office at 814-949-5540.
Content for a valid authorization includes:
- The name of the person or entity authorized to make the request (usually the patient)
- The complete name of the person or entity to receive the protected health information (PHI)
- A specific description of the information to be used or disclosed, including the dates of service
- The purpose of the requested use and disclosure
- The expiration date or event
- The patient signature and date
- A statement that the patient may revoke the authorization and how
- A statement that signing the authorization is not a condition of getting treatment
- A statement that the information disclosed may be subject to re-disclosure by the recipient
(Numbers 7, 8, and 9 are included in the text of our standard form)