To request a copy of your medical record for yourself or a third party, print out and complete the Authorization for Disclosure of Protected Health Information Form.  Mail or fax the completed form to:

University Health Services
Immunization and Medical Records Office
126 Student Health Center
University Park, PA 16802
Fax:  814-865-6982

Need to have the authorization form mailed or faxed to you? Please call 814-863-1975.

PLEASE NOTE:

• Completion of the form in its entirety is required. Incomplete forms will be returned to you by mail for completion, delaying the release of your medical information. For example, dates must be entered in a mm/dd/yr format.

• Fees apply to copies of medical records being released to employers, non-healthcare facilities, home addresses, or to insurance companies for application for coverage at the following rate: 
  
  $1.28 for pages 1-20
  $.95 for pages 21-60
  $.32 for pages over 60

Fees do not apply to copies of records being released to healthcare facilities or to insurance companies for settlement of a claim. 

If you have questions concerning whether or not charges will apply to your request, please call 814-863-1975.

• Processing time can take up to 5 business days.
• Faxing of medical information is done in time-sensitive situations only and only for the continuation of your care at another healthcare facility. 

           
If you have further questions regarding the release of information process, please call the Health Information Management Department at 814-863-1975.

• Download the Authorization for Disclosure of Protected Health Information Form
  

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