To request a copy of your medical records for yourself or to have your medical records sent to a doctor’s office or other third-party, download and complete the Authorization to Disclose Health Information form.
PDF (Adobe PDF document) — 514.5kb
All fields on the form must be completed and signed by you or your designated representative and clearly state the dates of service, the specific type of record(s) desired, and the reason for the request. If your designated representative is signing for you, please indicate why under the signature line.
You can also ask for copies of this form to be mailed, e-mailed or faxed to you.
Once completed, please use one of the following methods of communication to submit the form back to us. As soon as we receive your completed form, we can begin processing your request:
Or mail to:
Pentec Health Inc.4 Creek ParkwayBoothwyn, PA 19061ATTN: Compliance Department
In accordance with federal and state laws, processing fees and copying charges may apply.
If the record is being released directly to you, your physician or another health care facility, there is no charge associated with copying your records.
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