Medical Record

Release of Medical Records Requests


Medical Records Dept. hours Monday – Friday 8:15 a.m. – 4:15 p.m.

To Request Your Own Record(s):

To request a copy of your medical record(s), radiology reports and images, or to send a copy to someone on your behalf please complete the online Authorization for Release of Health Information form.

Please be sure to fill out the patient data fields, to whom the records are to be released to (if it is for yourself write SELF), what records are to be released, initials for special requests, sign and date.

You must send or upload an ID that has your name and signature along with the release form.

To Request Records for a Patient (Attorney, Insurance Company) 

To request a copy of a patients medical record, radiology reports and images, or an itemized bill please send in your request along with the Authorization for Release of Health Information form if required. The patient form must be filled out completely and it must contain the address where to send the records along with the patient signature and date. 

The release form is a PDF fillable form which can be filled out on a computer, smart phone, downloaded or printed.

Where to Send the Request Form:

You may return the form to the Medical Records Department by:

Email:
Fax: (570) 759-5525
Attention: Medical Records,
701 East 16th Street,
Berwick, PA 18603

In-person requests: Given the heightened concerns related to the spread of COVID-19, we can provide copies of your medical records via secure email and/or mail the copies to you. If you do not have access to a computer, smart phone or fax you can mail the completed form along with your handwritten signature to the address listed above.

There is a fee for copies of medical records. Upon receipt of your request an invoice will be sent to you. 

Please allow 10 days for your request to be completed.