Penn Form PDF Details

In the realm of healthcare, managing personal medical records and information is critical, not only for ongoing care but also for personal record-keeping and sharing with necessary third parties. The Penn Form plays a crucial role in this aspect, serving as an authorization tool that allows individuals to dictate how and with whom their health information is shared. Designed with patient privacy and information security in mind, the form covers several key areas, including the type of information to be disclosed - ranging from the entire medical record to more specific reports like lab results and physician orders. It also addresses special categories of information such as HIV/AIDS status, psychiatric care, and substance abuse treatment, giving patients the control to include or exclude these from the disclosure. The form outlines the locations and services involved, provides a section for specifying the recipient of the information, and states the purpose of the disclosure whether for personal use or for medical coordination. Moreover, it stipulates the format in which the information should be provided, highlighting options like paper copy or an electronic version. Importantly, the form recognizes the rights of patients and their representatives in the authorization process, including an understanding of the conditions under which the authorization may be revoked and the implications of refusing to sign the form. Completing and signing the Penn Form, therefore, equips individuals with a significant measure of control over their medical information, ensuring it is handled according to their wishes while maintaining compliance with regulatory standards for privacy and information sharing.

QuestionAnswer
Form NamePenn Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespenn form health, penn medicine release of records form, form uphs 0991 blank, medical release form penn medicine

Form Preview Example

 

 

 

 

 

 

 

NAME

 

SEX M

F

 

 

 

 

 

 

 

MR#

 

 

 

 

 

 

HUP

PPMC

PAH

 

AGE / DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION FOR DISCLOSURE OF

 

ACCOUNT#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH INFORMATION

 

 

(PATIENT PLATE IMPRINT)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name (First, Middle, Last)

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

City/State/Zip Code

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

Disclosed Information: (check all items to be released) ❑ Entire Record ❑ Abstract

 

 

 

 

 

❑ Discharge Summary

❑ Operative Report

❑ Lab Reports

❑ Radiology Images

 

 

 

❑ Discharge Instructions

❑ ER Record

❑ EKG/ECG Tests

❑ Medication Records

 

 

 

❑ History and Physical

❑ X-Ray Reports

❑ Progress Notes

❑ Physician Orders

 

 

 

❑ Consultations

 

 

 

 

 

 

 

 

 

 

 

❑ Other (please specify) _____________________________________________________________________________________

 

Covering the period(s) of care (list applicable dates of treatment) _____________________________________________________

 

Special Records:

 

 

 

 

 

 

 

 

 

 

 

I understand that information related to my diagnosis or treatment for AIDS/HIV, psychiatric care and treatment, treatment for drug

 

and alcohol abuse may be released as part of my health information. Please check appropriate box(es) below.

 

 

 

AIDS/HIV Information

 

Psychiatric Care/Treatment

 

Treatment for Drug or Alcohol use/abuse

 

 

 

❑ Yes, disclose

 

❑ Yes, disclose

 

❑ Yes, disclose

 

 

 

 

 

❑ No, do not disclose

 

❑ No, do not disclose

 

❑ No, do not disclose

 

 

 

Location of Services:

 

 

 

 

 

 

 

 

 

 

 

❑ HUP

❑ PAH

❑ PPMC

❑ Penn Home Care & Hospice Service (PHCHS)

 

 

 

 

 

❑ CPUP/CCA Outpatient Practice(s): __________________________________________________ Other:___________________

 

Information To Be Provided To:

 

 

 

 

 

 

 

 

 

 

Name of Person or Institution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Purpose/Use Of The Requested Information:

 

 

 

 

 

 

 

 

❑ Personal use by patient

 

 

 

 

❑ Sharing with other health care providers

 

 

 

❑ Other (please describe) ____________________________________________________________________________________

 

Format: ❑ Paper Copy ❑ Electronic Copy (provided on encrypted disk)

 

 

 

 

 

Authorization

 

 

 

 

 

 

 

 

 

 

 

I hereby authorize Penn Medicine to disclose the health information described above.

 

 

 

 

 

I understand that my authorization will automatically expire one hundred eighty (180) days after the date of signature on this form.

 

I understand that I may revoke this authorization at any time. I understand that to revoke this authorization, I must do so in writing.

 

I understand the revocation will not apply to information that has already been released in response to this authorization.

 

 

 

My refusal to sign this authorization will not affect my ability to receive treatment. By signing this form, I understand that I am

 

authorizing Penn Medicine to release information as described above.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Patient or Personal Representative

 

Print Name

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship of Personal Representative to Patient

 

 

 

 

Date

 

 

 

If Authorization is signed by someone other than the patient, please state reason. _________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE READ INSTRUCTIONS ON REVERSE

 

 

 

 

*UPHS099*

DO NOT USE UNAPPROVED ABBREVIATIONS

 

 

*UPHS099*

 

 

Page 1 of 2

 

 

 

 

 

 

 

 

 

 

UPHS-099-1

AEL 6/2010

 

 

 

 

 

 

 

 

 

 

Instructions For Completing The Authorization For Disclosure of Health Information

1.Please complete all sections of the Authorization For Disclosure of Health information.

2.The patient or legally authorized representative must sign and date the form.

Generally, only a patient may authorize release of his/her medical information. Exceptions to the rule are as follows:

a.Authorization of minors – If the patient is a minor (under 18 years of age), the authorization must be signed by a parent or legal guardian.

b.Emancipated minors – An emancipated minor is a minor under the age of 18, who is or has been married, is or has been pregnant or who is a high school graduate. Emancipated minors can authorize release of their medical information.

c.A minor who has been diagnosed with a venereal disease, a substance abuse problem or was treated to determine pregnancy may consent to treatment of that disease or condition and may authorize release of any medical information related to that disease or condition.

d.Authorization after death – An authorization must be signed by decedent's estate, or in the absence of an executor, the next of kin responsible for the disposition of the remains may give consent for the release of medical information.

e.Authorization of the incompetent patient – If the patient is deemed incompetent, then the patient's legally authorized representative must sign the authorization for release of information.

Penn Medicine reserves the right to request proof of representation.

The address should be for Inpatient, Emergency Department, and APU/SPU records:

Hospital of the University of Pennsylvania

Presbyterian Medical Center

Pennsylvania Hospital

3400 Spruce Street

Medical Records Department

Medical Records Department

Medical Records Department

51 North 39th Street

800 Spruce Street, 2nd Floor

1st Floor Founders

Myrin Basement

Philadelphia, PA 19107

Philadelphia, PA 19104

Philadelphia, PA 19104

 

Any Outpatient/Office Visit requests should be addressed to the individual Physicians’ Office.

Please Note

1.Penn Medicine will charge for copying records in accordance with Pennsylvania and New Jersey law, as applicable.

2.Penn Medicine will not send medical information by facsimile unless the information is needed for patient care and delay in the transmission of the information would compromise patient care.

3.Information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected by relevant federal and/or state law.

4.Penn Medicine will make reasonable efforts to comply with this request within thirty (30) days for information that is maintained or accessible on site and within sixty (60) days for information that is not maintained on site. If Penn Medicine is unable to comply with this request within the specified time periods, it may extend the applicable deadline for up to thirty (30) days by notifying you in writing.

5.Penn Medicine may deny this request under limited circumstances as provided for under federal law. Penn Medicine will notify you if it denies your request to access or obtain a copy of the requested information. If Penn Medicine denies this request, you may have the right to have a denial of your request reviewed by a licensed health care professional. To request such a review, please contact the Penn Medicine Chief Privacy Officer at the following address:

Penn Medicine

Office of Audit, Compliance and Privacy 3819 Chestnut Street, Suite 214 Philadelphia, PA 19104

DO NOT USE UNAPPROVED ABBREVIATIONS

Page 2 of 2

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1. Begin filling out your penn medicine authorization for disclosure with a selection of major blanks. Note all the important information and make sure absolutely nothing is neglected!

Writing section 1 in penn form

2. Once your current task is complete, take the next step – fill out all of these fields - Psychiatric CareTreatment Yes, AIDSHIV Information Yes disclose, Treatment for Drug or Alcohol, Penn Home Care Hospice Service, PPMC, PAH, Address, CityStateZip Code, Telephone Number, PurposeUse Of The Requested, Electronic Copy provided on, Sharing with other health care, I hereby authorize Penn Medicine, I understand that my authorization, and I understand that I may revoke with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step number 2 of filling in penn form

Regarding PPMC and I hereby authorize Penn Medicine, be certain you get them right in this section. The two of these are the most important ones in this form.

3. Completing Signature of Patient or Personal, Print Name, Date, Relationship of Personal, Date, PLEASE READ INSTRUCTIONS ON REVERSE, UPHS UPHS, DO NOT USE UNAPPROVED ABBREVIATIONS, Page of, and UPHS AEL is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Date, UPHS AEL, and DO NOT USE UNAPPROVED ABBREVIATIONS in penn form

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