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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!

fill out form
This field is for validation purposes and should be left unchanged.
Patient Name(Required)
Address(Required)

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

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.

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

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

HIV/AIDS - evaluation, diagnosis and/or treatment

Venereal Disease Information

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

This Information Will Be Used For the Following Purposes

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

River Valley Health is a Federally Qualified Healthcare Center located in Central Pennsylvania.
I understand authorizing this disclosure applies to all River Valley Health location and specialties.
I understand that in order to process this request, the above entity/entities 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 understand that this consent will expire one year after the date of signature or automatically when the records requested have been released.
I understand I may revoke this notification at any time, following the procedures outlined in the River Valley Health Notice of Privacy Practices.
I understand that authorizing the disclosure of this information is voluntary.
I understand that I can refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.
I understand that I have a right to receive a copy of this authorization.
I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient, and the information may not be protected by the federal privacy rules or by the state of Pennsylvania. If I am authorizing the release of HIV- related information, the recipient is prohibited from re-disclosing such information without my authorization unless permitted to do so under federal or state law.
I understand that I have the right to request a list of people who may receive or use my HIV- related information without authorization. If I experience discrimination because of the release of disclosure of HIV-related information, I may contact the Pennsylvania Human Relations Commission at (717)787-9780

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)
Signature (Parent/​Legal Guardian)
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Seeking After-Hours Care?

If you require assistance outside of regular office hours, please call 570-567-5400 and press 0 to be connected to our after-hours nurse triage. Our dedicated team is here to provide support and guidance when you need it most. Your health and well-being are our priority, 24/7.