Get Pa Mr 543.02 2023-2025

The PA MR 543.02 form is essential for authorizing the release of your medical records at Penn State Health. This guide provides clear and comprehensive instructions on how to complete this form online, ensuring you have the necessary information to navigate each section effectively.

Follow the steps to complete the PA MR 543.02 form online.

1. Click the ‘Get Form’ button to obtain the PA MR 543.02 form and open it for editing.
2. In the patient information section, enter your full name, date of birth, medical record number, phone number, and email address. Be sure to provide accurate contact information for potential follow-up.
3. Select the reason for your request by checking the appropriate box. Make sure to complete the addressee field to indicate who will receive the information.
4. Authorize the release by filling in the name of the employee or agent from Penn State Health who is permitted to discuss your healthcare information. Choose the specific information to be shared by checking the relevant box.
5. Specify any particular medical information you wish to include in this disclosure, such as behavioral health or substance use treatment, by checking the appropriate boxes.
6. Indicate where you received healthcare by checking all applicable locations from the list provided.
7. In the addressee field, fill in the name and address details of the person or organization to which you are releasing information.
8. Select the preferred format for receiving or releasing your medical information, such as electronic formats or paper.
9. Identify the specific types of medical records you are requesting by checking the relevant boxes and listing the dates of service for which you require records.
10. Sign and date the form in the patient or representative signature section. If applicable, include your relationship to the patient.
11. If oral authorization is given, provide witness information where necessary. Ensure all necessary fields are completed.
12. Review the entire form for accuracy before completing it. Once finished, you can save changes, download, print, or share the form as needed.

Take action now and complete the PA MR 543.02 form online to ensure your medical records are released promptly.