Medical Records Authorization (HIPAA)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — PENNSYLVANIA

This Authorization is executed in connection with a personal-injury matter so that the Patient and/or the Patient's attorney may obtain the Patient's medical records.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following health-care provider(s), facility(ies), clinic(s), pharmacy(ies), laboratory(ies), insurer(s), or custodian(s) of records to release the Protected Health Information ("PHI") described below:

3. RECIPIENT(S) — PERSON(S) AUTHORIZED TO RECEIVE RECORDS

4. RECORDS AUTHORIZED FOR RELEASE

Date range of records: [__/__/____] to [__/__/____] (or ☐ all dates).

Check each category of records to be released:

• ☐ Complete medical record / designated record set
• ☐ History and physical examination reports
• ☐ Office/progress/treatment notes
• ☐ Hospital and emergency department records
• ☐ Operative and surgical reports
• ☐ Physician orders
• ☐ Laboratory and pathology reports
• ☐ Radiology/imaging reports and films (X-ray, MRI, CT, mammogram, ultrasound)
• ☐ Physical therapy / rehabilitation records
• ☐ Prescription and pharmacy/medication records
• ☐ Billing statements, itemized charges, and payment records
• ☐ Diagnostic test results
• ☐ Discharge summaries
• ☐ Other (specify): [________________________________]

5. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

The following categories are protected by heightened confidentiality rules. They will NOT be released unless the Patient specifically initials the corresponding line below. My initials authorize release of that specific category to the Recipient(s) named in Section 3:

HIV/AIDS notice (35 P.S. § 7607 / Act 148): This information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is authorized by the Confidentiality of HIV-Related Information Act. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

42 C.F.R. Part 2 notice (substance use disorder records): Federal law (42 C.F.R. Part 2) prohibits any further disclosure of substance use disorder records unless the further disclosure is expressly permitted by the written consent of the person to whom they pertain or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any patient with a substance use disorder.

6. PURPOSE OF DISCLOSURE

The purpose of this disclosure is:

• ☐ Legal representation / evaluation, prosecution, or settlement of the Patient's personal-injury claim
• ☐ At the request of the Patient
• ☐ Other (specify): [________________________________]

7. HIPAA REQUIRED STATEMENTS

7.1 Expiration. This Authorization expires on [__/__/____], or upon the following event: [________________________________]. If no date or event is specified, this Authorization expires upon final resolution of the Patient's personal-injury claim or three (3) years from the date of signature, whichever occurs first.

7.2 Right to Revoke. I understand that I may revoke this Authorization at any time by delivering written notice to the provider/custodian identified in Section 2. Revocation will not apply to information already released in reliance on this Authorization before the provider receives my written revocation. (45 C.F.R. § 164.508(c)(2)(i).)

7.3 No Conditioning of Treatment. I understand that the provider may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

7.4 Redisclosure Notice. I understand that information disclosed under this Authorization may be redisclosed by the Recipient and may then no longer be protected by HIPAA. (Special-category records under Section 5 remain subject to the redisclosure prohibitions of 42 C.F.R. Part 2, 35 P.S. § 7607, and other applicable Pennsylvania law.)

7.5 Right to a Copy. I understand that I am entitled to a copy of this signed Authorization.

7.6 Voluntary. I understand that signing this Authorization is voluntary.

8. PENNSYLVANIA COPY-FEE AND RESPONSE-TIME NOTE

Under 42 Pa.C.S. §§ 6152 and 6155, a health-care provider or facility may charge a fee for producing medical charts or records. The Secretary of Health adjusts the maximum charges annually based on the Consumer Price Index. The schedule effective January 1, 2026 is:

• Pages 1–20: $2.03 per page
• Pages 21–60: $1.51 per page
• Pages 61–end: $0.53 per page
• Microfilm copies: $3.00 per page
• Search and retrieval: approx. $27.96 (may not be charged when the requester seeks their own personal health record)
• Flat fee — records to support a Social Security or federal/state needs-based claim: approx. $35.43
• Flat fee — records requested by a district attorney: approx. $27.96
• Actual cost of postage, shipping, and delivery may be added.

These per-page charges do not govern a request by the patient or the patient's personal representative; those requests are governed by HIPAA (45 C.F.R. § 164.524) and the HITECH Act, which limit the fee to the cost of labor, supplies, and postage. Under the HIPAA right of access, a covered entity must generally act on a request within 30 days (with one 30-day extension on notice).

9. SIGNATURE

Personal Representative (if Patient is a minor, incapacitated, or deceased)

Notary (optional)

Commonwealth of Pennsylvania, County of [________________________].

Subscribed and sworn to before me on [__/__/____] by [________________________________].

Sources and References

• HIPAA authorization core elements — 45 C.F.R. § 164.508: https://www.law.cornell.edu/cfr/text/45/164.508
• HIPAA right of access — 45 C.F.R. § 164.524: https://www.law.cornell.edu/cfr/text/45/164.524
• Substance use disorder records — 42 C.F.R. Part 2: https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2
• 42 Pa.C.S. § 6152 (subpoena of records; limit on charges): https://www.palegis.us/statutes/consolidated/view-statute?TTL=42&DIV=00.&CHAPTER=061.&SECTION=052.&SUBSCTN=000.
• PA Department of Health — Medical Record Fees (current CPI-adjusted schedule): https://www.pa.gov/agencies/health/resources/medical-record-fees
• Confidentiality of HIV-Related Information Act — 35 P.S. § 7607: https://codes.findlaw.com/pa/title-35-ps-health-and-safety/pa-st-sect-35-7607/
• Mental Health Procedures Act — 50 P.S. § 7111: https://www.palegis.us/statutes/unconsolidated/law-information?SessYr=1976&SessInd=0&ActNum=0143.