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Authorization for Release of Information

Instructions for Release of Medical Information

Fairmount Behavioral Health System is committed to protect and reserve your right to your Personal Health Information. Therefore, Health Information Service Department will not be releasing your information without a written authorization.  If you would like to obtain copies of your medical records, here are the steps:

1. Complete an Authorization of Release of Information Form by you or your guardian.

  • There is no fee for release to your primary care provider or any other health facilities.
  • Please note that there is a fee if you are requesting for yourself. See below for the fees stated by Department of Health, Notice regulated by Pennsylvania Act 26.
  • If you are requesting copies of your health information for SSI/SSA application, please note that SSI / SSA only need your date of service as they will request your record directly from us.

2. Return completed form to Health Information Service Department by one of the following method

  • Fax: 215-487-0964  Attn: Medical Record
  • Mail / drop off: 561 Fairthorne avenue Philadelphia, PA 19128 Attn: Medical Record

Please understand there are 30 days for Health Information Service Department to process your request but if you have questions regarding the status of your requests, please contact the Health Information Service Department, at 215-487-4057 between 8AM and 4PM during weekdays.

Fee amount for copies of Medical Record:

  • Basic Service Charges and retrieval of medical record  below:
  • $1.51 per page for 1-20 pages
  • $1.12 per page for 21-60 pages
  • $.38 per page for 61-end
  • Plus $2.50 postage and handling has been added.
  • Please note: Price may change per Department of Health.

Download ROI Form

Here to Assist You 24/7

If a psychiatric disorder or chemical dependency affects you or a loved one, please call 215-487-4100. We are available 24 hours a day, seven days a week to perform no-cost assessments and answer questions on programs and admissions.