White Rose Surgical Associates

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(717) 848-2067

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White Rose Surgical Associates, The care you deserve and the diligence you expect

Medical Records

As a patient of White Rose Surgical Associates, Ltd. you are entitled to view and/or receive copies of your medical records. In an effort to facilitate this process, please download and complete our HIPAA compliant authorization form, which allows us to release information contained in your medical record. We will only release information which was performed/dictated by this office. All other records must be obtained by the treating/testing healthcare provider.

To request copies of your medical records:

Please print the authorization Records Release Authorization
Complete this form in its entirety, including your name, date of birth and social security number. Please provide us with a detailed description of the information you are requesting as well as a complete mailing address and phone number for the individual(s) who will be receiving this information. Please provide an expiration date on this authorization. Make sure that you sign and date the form. It will not be honored unless all this information is complete and accurate.

The completed authorization can be submitted via Mail:
White Rose Surgical Associates, Ltd.
Attn: Medical Records Department
1601 South Queen Street, York, PA 17403

Fax to: (717) 848-2074 Attn: Medical Records Department

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Patient Forms
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Records Release Authorization

Patient Information Form

Patient Medical History Form

Financial Responsibility Form

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