PATIENT REQUEST FOR COPY OF MEDICAL RECORDSAuthorization for Disclosure of Health Information

University of Pennsylvania

Patient Name (Last, First) ____________________________________________________________

Penn Student Identification Number: _______________________ Date of Birth: ________________

Current Student: Yes No

If NO, graduation date or last month enrolled as student: ______ (month)/______ (year)

Special Records: I understand that information related to my diagnosis or treatment for AIDS/HIV,psychiatric care and drug and alcohol abuse may be released as a part of my health information,based on the choices I have made below, where my consent is legally required.

Please check appropriate check boxes:

AIDS/HIV Treatment Yes, disclose No, do not disclose

Psychiatric Care/Treatment Yes, disclose No, do not disclose

Treatment for Drug/Alcohol Use/Abuse Yes, disclose No, do not disclose

If you select “No” for any of these categories, we will make all reasonable efforts to remove theseelements from your chart prior to disclosing the information. However, if you wish to be absolutelycertain that such information is not shared with third parties, it is best to request that records be sentto you, so that you can personally review the materials and decide which parts to share with others.

Request for Medical Records:

Immunization Report Only

Full Chart

3535 Market Street, Suite 100 Philadelphia, PA 19104 Phone: (215)746-3535 Fax: (215)746-0847 Email: vpul-shsmr@pobox.upenn.edu

Information to be provided to:

Name of Person or Institution: _________________________________________________________________________

Address: _________________________________________________________________________

Phone Number: ___________________________ Fax Number______________________________

Please choose one:I will pick up a paper copy in Student HealthPlease Mail a Paper Copy to Above AddressFax. Please Provide Fax Number _________________________________________________Email. Please Provide Email Address ___________________________________________

Important: I understand that unencrypted email is not secure and therefore may be intercepted byothers. I understand that email may be misdirected and easily forwarded to unintended recipients.By choosing to receive my health information by email, I am accepting these risks.

Purpose of Use:

Personal Use by PatientSharing with Other Healthcare ProvidersOther (please describe) ____________________________________________________

I hereby authorize the Student Health Service to disclose the health information described above. I understand that after my records have been released, updated copies of my records will require a newauthorization (in order to ensure my privacy of an actively changing health record). I understand that Imay revoke this authorization at any time. I understand to revoke this authorization I must do so inwriting. I understand that the revocation will not apply to any information that has already been releasedin response to this authorization. My refusal to sign this authorization will not affect my ability to receivetreatment. By signing this form, I understand that I am authorizing Student Health to release informationas described above. Information used or disclosed pursuant to this authorization may be subject to theredisclosure by the recipient and may no longer be protected by the relevant federal and/or state law.

Authorization:

_____________________________________________________________________________________Signature of Patient or Personal Representative Print Name Date

_____________________________________________________________________________________Relationship of Personal Representative to Patient

If relationship is other than patient, please state reason________________________________________

3535 Market Street, Suite 100 Philadelphia, PA 19104Phone: (215)746-3535 Fax: (215)746-0847 Email: vpul-shsmr@pobox.upenn.edu