Obtain Copies of Your Medical Records

The results of all tests and medical treatment that you received during your hospital visit are documented and maintained in a medical record file(s). Also included are physician reports from examinations, surgery reports, treatment and medications, and observations by nurses and other members of your healthcare team. This information is combined to make up your medical record.

How to obtain copies of medical records

Requests for medical records may be made by returning an Authorization for Disclosure of Health Information form via mail or fax to 610.356.3167.

Records can be released to anyone that the patient authorized (in writing) to receive such information. A valid authorization must contain the following information, or the request will be returned.

  • Patient's full name and date of birth
  • Specific information being requested (e.g., type of report/information and dates of service, etc.)
  • Purpose for which the information may be disclosed
  • To whom the information should be sent (name and address)
  • Authorization expiration date
  • The patient's signature or a patient's legal representative's signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney
  • Date of signature

In most cases, the Authorization for Disclosure of Health Information form for patients under the age of 18 must be completed by a parent or legal guardian.

Please choose the appropriate form below:

Sensitive information

Certain information requires a special authorization covering sensitive information. This may include psychiatric, drug and/or alcohol abuse, HIV/AIDS, and sexual abuse information. Authorizations for sensitive information must specifically refer to the information that is to be released.

Requests for medical records of deceased patients require a letter of authority in addition to your signed request. The letter of authority is given to the executor or administrator of a person's estate by the Probate Court upon his/her death. Releasing records to anyone other than the executor or administrator is not permitted by law. Please include your phone number in the event we need to contact you for additional information concerning your request.

Instructions on how to request an amendment to your PHI/medical record

Please submit the completed form via fax or mail:

Fax: 610.356.3531
Phone: 484.476.1721

Address to mail:
Health Information Management
Main Line Health
3809 West Chester Pike, Suite 110
Newtown Square, PA 1907

Requesting a new COVID-19 vaccine card

For patients who received vaccination with us and have misplaced their vaccination card, please print the following form and submit the completed form via fax or mail. Please allow up to 2 weeks to receive a new card in the mail. Main Line Health will not be able to provide any COVID-19 vaccine information for any doses you received elsewhere. To receive vaccine information from any external providers, please contact the provider who administered your vaccine.

Fax: 610.356.3531
Phone: 484.476.1721

Address to mail:
Health Information Management
Main Line Health
3809 West Chester Pike, Suite 110
Newtown Square, PA 19073

You may also receive a record of your vaccine through the following options:

  • MLH MyChart account:
    • If you have a MyChart account with us, then please know you can also login to your MyChart account to access your immunization history. You must be logged in from a DESKTOP to view all necessary details regarding your vaccine information.
    • Login to your account and go to “Menu” from the top left and choose “Health Summary”
    • Once your “Health Summary” page loads, choose “Immunizations”
    • You should see “Sars-cov-2 (Covid-19) Vaccine”, click on “View Details”
    • On that page you’ll find all the details of your immunization. You can also print this page for your records if you would like.
  • Contact the state department of health:

Related reproduction fees

In accordance with PA state law, the following fees* are charged when providing copies of medical records. Or, we will be happy to provide copies directly to your physician at no charge:

Per page charge, pages 1-20 $1.70
Per page charge, pages 21-60 $1.26
Per page charge, pages 61-end $0.44
Microfilm copies per page $2.51
Postage fees will also be added if records are mailed.
Flat fee for production of records to Support Social Security $31.94
Fee for Reproducing Diagnostic Images:
First request: Free of charge
Second request: 25.00 plus $1.00 per page of images
Flat fee for supplying records requested by a district attorney $25.20
Search and retrieval of records: Cost not to exceed $25.20
(search/retrieval fee not assessed for individual requests for records)

**rates effective January 1, 2022 and subject to change annually at the discretion of the Secretary of Health