The Children's Hospital of Philadelphia - Notice of Privacy Practices

Obtaining Medical Records

To request that a copy of your/your child's medical record be released to you or to an organization (i.e., school, day care provider, employer), complete a request form (see table below) and send it by mail or fax or deliver it in person to the Children's Hospital location indicated below. Because a signature is required to release your information, we are not able to process requests received by telephone or email. If you pick up a copy of the medical record in person, we will ask for photo identification. There may be a fee for providing copies of the medical record.

To request information about:	Use this form and send to the location indicated below:
Inpatient services provided at the Main Hospital or Children's Seashore House, including Emergency Department visits, day surgery, and stays lasting 23 hours or longer	Authorization to Release/Obtain Patient Information (80K) Health Information Management Department The Children's Hospital of Philadelphia 34th and Civic Center Boulevard Level A, Room 246 Philadelphia, PA 19104 Telephone: 215-590-3640 Fax: 215-590-4193
Outpatient services (i.e., doctor visits, blood tests) provided at the Main Hospital *	Authorization to Release/Obtain Patient Information (80K) Send to the department where service was provided or call 215-590-1000 to reach the appropriate department.
Outpatient services (i.e., occupational or physical therapy, speech, rehabilitation, psychology) provided at Children's Seashore House	Authorization to Release/Obtain Patient Information (80K) Health Information Management Department The Children's Hospital of Philadelphia 34th and Civic Center Boulevard Level A, Room 246 Philadelphia, PA 19104 Telephone: 215-590-3640 Fax: 215-590-4193
Services provided at Specialty Care Centers in Pennsylvania and New Jersey	Authorization to Release/Obtain Patient Information (80K) Send to the Specialty Care Center where service was provided.
Services provided at Kids First practices	Authorization to Release/Obtain Patient Information (80K) Send to the Kids First practice where service was provided.
Services provided at Primary Care Centers	Authorization to Release/Obtain Patient Information (80K) Send to the Primary Care Center location where service was provided.
X-rays or other radiological images, including CT scans, MRIs and ultrasounds. (Radiological images are released on CD.)	Authorization to Release/Obtain Patient Information (80K) The Children's Hospital of Philadelphia Radiology Department Radiology File Room 34th and Civic Center Boulevard Philadelphia, PA 19104 Telephone: 215-590-1000 Fax: 215-590-4783

* If a test was ordered by a physician who is not affiliated with Children's Hospital, please
contact that physician directly.

Related Links
Safeguarding Your Medical Information
Your Privacy Rights
Forms and Documents Library

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