Release Forms for Protected Health Information

Release of Protected Health Information (PHI)

To request the disclosure of health records, please complete the appropriate Release of Protected Health Information (PHI) form. This form authorizes us to share health information with designated individuals, providers, or organizations in accordance with HIPAA guidelines. Please ensure all sections are filled out accurately to avoid delays. Download the appropriate form below and follow the submission instructions provided.

Authorization for release of health information by PrimeCare Medical, Inc. (PA, MD, NH)

Authorization for release of health information by PrimeCare Medical of New York, Inc. (NY)

Authorization for release of health information by PCM Correctional Health Care, Inc. (FL)

Authorization for release of confidential substance use disorder (SUD) patient records by PrimeCare Medical, Inc. (PA, MD, NH)

Authorization for release of confidential substance use disorder (SUD) patient records by PrimeCare Medical of New York, Inc. (NY)

Authorization for release of confidential substance use disorder (SUD) patient records by PCM Correctional Health Care, Inc. (FL)