Release of Medical Records Requests
Clinic Record Pick-up Announcement
Medical Records Dept. hours Monday – Friday 7:30 a.m. – 4:00 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 Authorization for Release of Health Information form (Click here to download) (Click here to fill the online 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 mail or eFax 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 patient’s 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 (Click here to download)(Click here to fill the online 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 form which can be downloaded and filled by hand.
Where to Send the Request Form:
You may return the form to the Medical Records Department by:
Fax: (570) 273-0989
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.
Upon receipt of your request an invoice will be sent to you. Please feel free to call (570) 759 5224 should you have any questions regarding your medical records.
Please allow 10 days for your request to be completed.