Lancaster Pediatric Associates, Ltd.
WILLIAM R.A. BOBEN .Jr, M.D.
STEVEN F. KILLOUGH, M.D.
SHAKTHI KUMAR, M.D.
PIA BOBEN FENIMORE, M.D.
BRENT D. PAWLSON,M.D.
JILL F HIGH, M.D.
JASON L. GOTTLIEB, M.D.
CARRIE S. EDWARDS, M.D.
MARY E. DEPOE, CRNP
ELIZABETH A. NEUMANN,CRNP
TREVA M. STANTON,CRNP
GLORIA . CISSNE,CRNP
AMANDA KATCH,CRNP
The information in this authorization is confidential and protected by Federal and State law from unauthorized
use of disclosure.
I, ________________________________________________________________________________, hereby authorize:
Parent /Patient Name*
Home Address
__________________________________________________________________________________________________
(Physician, Facility Name & Address)
to release to Lancaster Pediatric Associates, LTD., information from the medical record of:
Patient Name: ____________________________________________________________
Date of Birth: ______________________
Medical Information to be released:
Complete Records ______________
Last two (2) years _______________
Specific Records/Dates: ___________________________________________________________
I certify that I understand the contents of the form. This consent begins on the date of signature and is valid for a period of 90 days.
Pennsylvania law prohibits Lancaster Pediatric Associates, LTD. from making further disclosure of information unless written
authorization for further disclosure is expressly permitted from the person to whom it pertains or is otherwise permitted by law.
General authorization is not sufficient for this purpose.
__________________________________________
_____________________________________________
(Parent/Patient Signature)
(Relationship to Patient)
__________________________________________
(Date)
Please note, you may be charged a fee from the Physician/Facility releasing your medical records.
*IMPORTANT – Patients fourteen (14) years of age and older treated for mental illness, drug abuse,
alcohol abuse or birth control measures must sign this authorization.
Patients (18) years of age or older must sign this authorization.
LANCASTER GENERAL HEALTH • 2106 HARRISBURG PIKE, SUITE I • LANCASTER. PA 17601-2644 • PHONE. 7 17-291-593 1 • FAX 717-291-5818
WILLOW LAKES HEALTH CENTER • 222 WILLOW VALLEY LAKES DRIVE, SUITE 100• WILLOW STREET. PA 17584-9671 • PHONE 717-464-9555 • FAX 717-464-9434
www.lancped.com