Medical Records Release

Medical Records

Please complete the appropriate form below to fulfill your request. If you have any questions, please reach out to our Medical Records Team at 717-761-0930 and we will be happy to assist you.

Requesting My Medical Records

Please complete the form below to authorize your provider or healthcare team to send your medical records to Jackson Siegelbaum Gastroenterology.

If you cannot view the form below, you may click here to access our HIPAA compliant Authorization for Use and Disclosure of Medical Information form.

Releasing My Medical Records

Please complete the form below to authorize Jackson Siegelbaum Gastroenterology and/or West Shore Endoscopy Center to release your medical records to your provider or healthcare team.

If you cannot view the form below, you may click here to access our HIPAA compliant Authorization for Use and Disclosure of Medical Information form.