The results of all tests and medical treatment that you received during your hospital visit are documented and maintained in a medical record file(s). Also included are physician reports from examinations, surgery reports, treatment and medications, and observations by nurses and other members of your healthcare team. This information is combined to make up your medical record.
How to obtain copies of medical records
Requests for medical records may be made by returning an Authorization for Disclosure of Health Information form via mail or fax to 610.356.3167.
Records can be released to anyone that the patient authorized (in writing) to receive such information. A valid authorization must contain the following information, or the request will be returned.
- Patient’s full name and date of birth
- Specific information being requested (e.g., type of report/information and dates of service, etc.)
- Purpose for which the information may be disclosed
- To whom the information should be sent (name and address)
- Authorization expiration date
- The patient’s signature or a patient’s legal representative’s signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney
- Date of signature
In most cases, the Authorization for Disclosure of Health Information form for patients under the age of 18 must be completed by a parent or legal guardian.
Please choose the appropriate form below:
- Request your medical records from our hospitals, health centers and physician practices (PDF)
- Request records from Mirmont Treatment Center - Lima (PDF)
- Request records from Mirmont Treatment Center - Outpatient locations in Exton and Broomall (PDF)
Certain information requires a special authorization covering sensitive information. This may include psychiatric, drug and/or alcohol abuse, HIV/AIDS, and sexual abuse information. Authorizations for sensitive information must specifically refer to the information that is to be released.
Requests for medical records of deceased patients require a letter of authority in addition to your signed request. The letter of authority is given to the executor or administrator of a person’s estate by the Probate Court upon his/her death. Releasing records to anyone other than the executor or administrator is not permitted by law. Please include your phone number in the event we need to contact you for additional information concerning your request.
Instructions on how to request an amendment to your PHI/medical record
Please submit the completed form via fax or mail:
Fax # 610-356-3531
Address to mail:
Health Information Management
Main Line Health
3809 West Chester Pike, Suite 110
Newtown Square, PA 1907
Related reproduction fees
In accordance with Pennsylvania state law, the following fees* are charged when providing copies of medical records. Or, we will be happy to provide copies directly to your physician at no charge.
|Pages 1–20||$1.46 per page|
|Pages 21–60||$1.08 per page|
|Pages 61–end||$0.36 per page|
|Microfilm copies||$2.16 per page|
|Postage fees will also be added if records are mailed.|
|Flat fee for production of records to Support Social Security||$27.48|
|Fee for reproducing diagnostic images:|
|First request:||Free of charge|
|Second request:||$25.00 plus $1.00 per page of images|
|Flat fee for supplying records requested by a district attorney||$21.69|
|Search and retrieval of records: Cost not to exceed||$21.69|
|(search/retrieval fee not assessed for individual requests for records)|
*rates subject to change annually at the discretion of the Secretary of Health