Release Medical Information

Heritage Valley Health System works with an outside source to coordinate providing copies of medical records to patients and/or authorized people.


Download Release Form

Download the Medical Records Release Form, complete it and send to the Medical Records Department:

  • Heritage Valley Sewickley
    Medical Records Release of Information
    720 Blackburn Road
    Sewickley, PA 15143 

Note:  Please complete all appropriate sections on the form. Make sure to include a phone number where you can be reached in case additional information is required. On page 2, a signature is required under both the Patient Rights section and the Sensitive information section of the form in order for the form to be processed. 


Request Release Form

Request the Medical Records Release form be sent to you by contacting the appropriate Medical Records Department:

  • Heritage Valley Beaver: 724.773.7600
  • Heritage Valley Sewickley: 412.749.7181 
  • Heritage Valley Kennedy: 412.777.6292

Fees

Heritage Valley Health System works with an outside service to process medical records requests. Fees for processing a medical record are based on fees set by the Pennsylvania Department of Health.

Rates:

Patients & Patient Representatives
Electronic Copy: Flat fee of $6.50/request (CD)
Any request on Paper or Paper/Electronic combination: $0.10 per page/request
Paper uploaded to CD: $0.08 per page/request

Attorneys & Copy Services
$23.04 search and retrieval fee
$1.55/ page (1-20 pages)
$1.15 / page (21-60 pages)
$0.39 / page (61 + pages)
$2.29 / page (microfilm copies)
Actual postage

District Attorney and Public Defenders
Copy Charges: $22.04 / request

Requests for Social Security
Copy Charges: $27.92 / request

Requests for Disability Benefits
Copy Charges: 
$29.19 / request

Requests for continued care, Military
Copy Charges: No charge


Questions? 

  • For Heritage Valley Beaver records, contact Release of Information staff at 724.773.7600
  • For Heritage Valley Sewickley records, contact Release of Information staff at 412.749.7181
  • For Heritage Valley Kennedy records, contact Release of Information staff at 412.777.6292