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Medical Information Release Form

Medical Information Release Form

Your Health Information

If you need a copy of your health information (medical record) for any reason, you must make your request in writing on a HIPAA compliant authorization form and forward to the:

Medical Record Department
Correspondence Section

St. Mary Medical Center
1201 Langhorne-Newtown Roads
Langhorne, Pennsylvania 19047

Please be advised that in Pennsylvania, the state sets the fee structure for obtaining copies of your medical records as described in Act 26 for the Commonwealth of Pennsylvania. Our Correspondence Coordinator will contact you upon receipt of your request to review any associated fees, if applicable. Please include a phone number where we can reach you.

For your convenience, there is an authorization form that you can print out and fax to Health Information Management at  215-710-5822.  Click here  

For additional information, please contact our Correspondence Coordinator at 215-710-2084