Medical Record Forms

PATIENTS: 

You can have copies of your medical records sent by:

• Secure email
• Fax
• Mail
• Local pick up 

 To request a copy of your medical records: Patients can request copies of their medical records electronically by completing our form entitled “Authorization for Use or Disclosure of Health Information” and by presenting valid identification. This completed authorization must be dated and signed.

1. Download this document.
2. Complete the document.
3. Send the document and identification:
1. EMAIL: mwilliams@citywideccs.org or
2. FAX: (215) 291-1880 or Electronic Fax - 866-375-0212
3. HAND DELIVER : to the hospital front lobby at 533-539 East Allegheny Avenue Philadelphia PA, 19134 ****Drop off before 5pm****

Valid Identification: Medical records will not be released without the requestor providing proper identification. A government issues identification is required. If you are requesting records for someone other than yourself, you must provide supporting legal documentation such as:

• Power of Attorney
• Advance Health Care Directive
• Executor of the Estate
• Court order/Conservatorship appointed by the court

Medical Provider Requests for Medical Records/Results - For continuity of care purposes, please fax or email your request on your letter head and include the following information on your request:

• Patient Name
• Date of Birth
• Dates of Services being requested
• Type of reports being requested

Your call back/contact information including:

• Contact
• Call back number (including extension number)
• Fax number

Submit your requests via FAX or EMAIL

Fax: (215) 291-1880

Email: mwilliams@citywideccs.org