HIPAA Forms

These forms are available for you to download, complete, and mail or fax to the Medical Records Department.
Fax: 484-628-9777
Mail: Medical Records Department
The Reading Hospital and Medical Center
PO Box 16052
West Reading, PA 19612-6052

Request to Amend Protected Health Information

  • If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Hospital.
  • To request an amendment, your request must be made in writing and submitted to the Director of Medical Records at The Reading Hospital. In addition, you must provide a reason that supports your request.
  • We have the right to deny your request for an amendment if it is not in writing, or does not include a reason to support the request.
  • In addition, we may deny your request if you ask us to amend information that:
    • was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
    • is not part of the information which you would be permitted to inspect and copy;
    • or is accurate and complete.

Request to Restrict Use and Disclosure of Health Information

  • You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or healthcare operations.
  • You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend.
    For example, you could ask that we not use or disclose information about a surgery that you had.
  • We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
  • To request restrictions, you must make your request in writing to the Director of Medical Records at The Reading Hospital.
  • In your request, you must tell us:
    • what information you want to limit;
    • whether you want to limit our use, disclosure, or both;
    • and to whom you want the limits to apply.

        For example, you may ask that we not disclose information to your spouse.