Authorization to Use and/or Disclose Health Information
UPMC Hamot Surgery Center
Please fill out the following form so that our office can prepare your medical records request.
**Please note: Our office requires 5 working days to prepare your requested medical records.
By selecting the box(es) below, I specifically authorize the use or disclosure of the following health information and/or records, if such information and/or records exist.
Except to the extent that action has already been taken in reliance upon this authorization, I understand that I may revoke this authorization at any time by giving written notice to UPMC Hamot Surgery Center, LLC.
Unless revoked earlier, this authorization will expire 60 days from the date of signing.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits. I may inspect or copy any information to be used or disclosed under this authorization.
I also understand that if the person or entity receiving this information is not a health care provider or a health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my health information under other applicable state or federal laws and regulations.
I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (either directly or indirectly) for doing so.
Thank you for submitting your request. Please allow 5 business days for us to prepare your requested medical records.