Release of Medical Information request form

River Valley Health is committed to providing quality, inclusive care. Ensuring we have as much information as possible prior to your first visit is very important. Please make sure this Release of Information is filled out entirely before submitting. If you have any questions regarding this form, please call us at (570) 567-5400. Once we receive this form, we will contact you to schedule your new patient appointment!

Patient Name(Required)

First Last

Date Of Birth(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

This authorization permits River Valley Health to receive from and/or share information with the below healthcare provider/organization/family member for the purpose of continuation of medical treatment:

Heathcare Provider Name

Heathcare Provider Address

Street Address Address Line 2 City State ZIP Code

Healthcare Provider Phone

Healthcare Provider Fax

SPECIFIC INFORMATION TO RELEASE: Select items you do not wish to release or that do not pertain to your records.

Labs x 1yr

Most Recent Cervical/Colon Cancer Screening

Current Med List

Most Recent Mammogram

Last two (2) Office Visit Notes

Immunization Records

Imaging Reports x 1 yr

Other

I understand that in order to process this request, the above entity(ies) may utilize a contracted medical record copying service and I further authorize the release of my medical record information to such record services for this purpose. I also understand that this consent will expire one year after the date of signature or automatically when the records requested have been released. You may revoke this notification at any time, following the procedures as outlined in the River Valley Health Notice of Privacy Practices.

By initialing these 5 items, I acknowledge that information regarding these topics may be released as part of my medical information.

Patient Initials(Required)

Parent/Guardian Initials

Alcoholism or drug abuse or drug dependency - evaluation, diagnosis and/or treatment

Patient Initials(Required)

Parent/Guardian Initials

Mental health/rehabilitation or neuro-psychological issues - evaluation, diagnosis and/or treatment

Patient Initials(Required)

Parent/Guardian Initials

HIV/AIDS - evaluation, diagnosis and/or treatment

Patient Initials(Required)

Parent/Guardian Initials

Venereal Disease Information

Patient Initials(Required)

Parent/Guardian Initials

Genetic testing, test results, counseling, reports, treatment, and referral information

Note: If patient is under 18 years of age and is not an emancipated minor or is unable to sign authorization because of physical condition or age, the parent or legal guardian must sign.

Signature (Patient)(Required)

Date Of Signature(Required)

Signature (Parent/Legal Guardian)

Date Of Signature

Last 4 digits of Patient's Social Security Number(Required)

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This field is for validation purposes and should be left unchanged.

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Release of Medical Information request form

Our Locations

Williamsport Medical & Dental | 471 Hepburn Street, Williamsport, PA 17701

Williamsport Specialty Care | 431 Hepburn Street, Williamsport PA 17701

Williamsport Express Care | 431 Hepburn Street, Williamsport PA 17701

Lock Haven Medical & Dental | 124 East Walnut Street, Suite 2, Lock Haven, PA 17745

(570) 567-5400

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