Medical Records Request Form

Please complete this form in its entirety to request medical records. Medical Records requests have an average turn-around time of 30 days, however records requests may take longer for records that are requested from years past. Pennsylvania law requires for medical records to be retained for a period of 7 years after which they are destroyed in accordance with the law. Only individuals who have received services may use this form to make medical records requests. Legal guardians, care givers, and administrators of estates may also complete this form to request records. Requestors, such as attorneys, human service organizations, and government agencies must submit a letter requesting medical records and should not use this form to request records. Records must be picked up from the location by the person receiving services and must sign a receipt that they picked up the records. We do not mail records out.

Program where Treatment was Provided (check all that apply)

Records provided are the following:

10 + 2 =