It may take up to five business days to fulfill the request.

1. I authorize the Pennsylvania Department of Health (Department) to disclose individual newborn screening information/results obtained from the records of:

2. Type of Newborn Screening Results Requested and Reason for Disclosure: (dried blood spot test results, critical congenital heart defect screening results, and/or hearing screening results). *

3. List the specific purpose for each result requested: (such as: use for direct patient care*, early intervention services, or college application) *

This information is to be disclosed to:

*Hospitals and primary care providers in Pennsylvania must obtain all screening results from nbs.pa.gov

4. I understand that:

  1. This authorization may be revoked at any time by writing to the Department except to the extent that information has already been disclosed. If information has already been disclosed in reliance on this authorization, revocation will only prevent future disclosure.
  2. Treatment, payment, enrollment, or eligibility is not conditioned on the provision of this authorization.
  3. Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient identified in this Authorization. and may no longer protected by federal privacy regulations.
  4. The Department, its programs, services, employees, officers, and contractors are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized.
  5. I may refuse to sign this authorization.

5. This authorization expires once the results have been received by the above individual or organization.

I certify under penalty of law that I am accessing MY OWN birth record information, or I have written authorization from the record holder to access the requested information, and that all information contained herein is true and correct. I understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 PA. C.S. Section 4904(b))


For questions on form completion please call 717-783-8143 or email RA-TCNBSAdmin_Fax@pa.gov