Medical Records Request

Use this form to authorize your healthcare provider or healthcare team to send your medical records to Jackson Siegelbaum Gastroenterology.

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

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