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.
Schedule Pick-up for Medical Records
Please call the Medical Records Department at 724.773.7600.
Select Patient, Medical Records, Release of Information, then Schedule Pick-up / Other.
Request Release Form
Request the Medical Records Release form be sent to you by contacting the Medical Records Department at 724.773.7600.
Select Patient, Medical Records, then Release of Information.
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
| How the PHI is Maintained | Requested Format of PHI | Reasonable, Cost-Based Fee |
| Hybrid (includes Electronic Health Record (EHR) and/or paper). | CR-ROM | Flat fee of $6.50 (inclusive of actual labor, supplies) plus postage and applicable sales tax. |
| Hybrid (includes Electronic Health Record (EHR) and/or paper). | paper mailed, picked up or emailed | Flat fee of $6.50 (inclusive of actual labor, supplies) plus applicable sales tax. Postage if mailed, no postage if emailed. |
| Paper only (does not include Electronic Health Record (EHR)). | CD-ROM | Flat fee of $6.50 (inclusive of actual labor, supplies) plus postage and applicable sales tax. |
| Patient Portal – Follow My Health | Smartphone, laptop or computer | No charge. |
Attorneys & Copy Services
$28.01 search and retrieval fee
$1.89 / page (1-20 pages)
$1.40 / page (21-60 pages)
$0.49 / page (61 + pages)
Actual postage
District Attorney and Public Defenders
Copy Charges: $28.01 / request
Requests for Social Security or Federal/State Financial Needs-Based Service
Copy Charges: $35.50 / request
Requests for Disability Benefits
Copy Charges: $35.50 / request
Questions?
For Heritage Valley Health System records, contact Release of Information staff at 724.773.7600