Form Instructions 4562 for Allentown Pennsylvania 2024-2025

Form Instructions 4562 for Allentown Pennsylvania: What You Should Know

This includes information such as: • Information relating to the health care practitioner who provided the PHI, • Information on the subject in the request for PHI, and • For any specific questions relating to the protected health information in the request for PHI, contact the appropriate agency for health care provider information. If you do not have sufficient information to complete this form, contact our Tax Protection Coordinator at:. NOTIFICATION OF REQUEST On or before the 30-day anniversary of the date the request is received by the Department, the Department must notify the applicant if the request has been fulfilled. The Department will also inform the applicant of any deficiencies identified in this request. No more than 10 Phis may be released under Section 6105 of the Internal Revenue Code during any tax year. Include the following information in your request by using the “additional information” area at the bottom of Form 4562 : • The requester's name and address and number, • Identification of the PHI records to release, • Any specific queries regarding the records as identified in the request, • A complete copy of each of the completed original forms for 2025 and 2017. If the request is for more than 10 Phis, please also print a separate form for each request. After submitting Form 4562 and before the expiration date in subsection (q)(4) of §6115 of the Internal Revenue Code, a covered entity has 60 days from the receipt of a covered entity identification number (IN) or a covered entity authorization number (CAIN) to submit a request for PHI to the Department for release to an authorized user outside the Department and submit the requested documents to the Department. The Department's disclosure date for a covered entity information request shall not begin until the Department is informed that the requester's IN or CAIN has been received by the Department, that a covered entity has submitted a request through any of its channels, and that the entity has paid the required remittance to the Department.

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