Medical Records Requests

To inspect or request a copy of your records or your child's records, please print and complete the Release of Information form.
Release of Information

All release of information forms must be complete and accurate.
A valid authorization must include the following:

  • Name and Date of Birth

  • A valid phone number where the requestor can be reached

  • Specific information requested must be initialed

  • Requested Dates of Treatment must be specific and complete

  • To whom the information is to be sent - must be complete with name, address, and phone number

  • Purpose of the authorization

  • Effective Consent Dates

  • All statements must be initialed on the release

  • The individual must print name, provide a signature and date the release

  • A witness signature must be provided by an individual who has verified the identity of the person requesting information

  • Individuals 14 and older must complete a release of information for records. Release forms for children under the age of 14 must be completed by a legal guardian

  • Requests for deceased individuals must include a copy of the death certificate as well as evidence of executorship of the state

Please send your complete and accurate release to:

1. By Mail:

John F. Kennedy Behavioral Health Center

Medical Records Department

112 North Broad Street

Philadelphia, PA 19102

(215) 568-3261

2. By Fax:

Attention: Medical Records

(215) 568-1735

Once an accurate and complete release of authorization form is received, please allow up to 30 days to receive records. Any incomplete release forms will not be processed. If there is a copying fee, individuals will be notified of the charge and pre-payment will be required prior to receipt of copied records.