Request for release of medical information

Written request is required. 

Complete Authorization for Disclosure of Protected Health Information (Release) Form.

Include exact information requested (i.e., immunization record, progress notes, most recent PAP report, etc.)

Information will be sent by first-class mail.  There is no charge for your first request; subsequent requests for the same material will result in a $10 charge payable prior to the information being forwarded (check should be made payable to Bucknell University and sent with request for information to Bucknell University, Ziegler Health Center, Lewisburg, PA  17837).

Download Authorization for Disclosure of Protected Health Information