Patient Confidentiality & Privacy


Photocopies of your records are available upon request and shall be released only with an appropriate patient authorization and/or in accordance with applicable state and federal laws. An Authorization for Disclosure of Medical Information is available at the Correspondence desk in the Health Information Management Department; OR you may use the link provided to print a valid authorization form to fill out and fax to us. If you are aware of any protected information in your records (ie. psychological or psychiatric impairments(s), drug abuse, alcoholism, or human immunodeficiency virus (HIV) infection, including acquired immunodeficiency syndrome (AIDS), or testing for HIV) you will have to sign a special authorization form, which can be obtained from the Correspondence Coordinator in the Medgen. This is for compliance with all federal and state laws, and the purpose is to safeguard your confidentiality. In the course of processing your request, the Correspondence Coordinator will contact you if a special authorization is necessary to release your medical records. In order to process your request expeditiously, the following information should be included:

  • Patient Name
  • Date of Birth
  • Date(s) of Service
  • Information needed
  • Purpose of the request
  • Name of individual authorized to receive the information
  • Signature of patient, legal guardian or individual authorized by law to release medical records on behalf of the patient

Please include a phone number where we can reach you in case there are questions about your request.

 Click here for a convenient form to fill out and fax to 877-611-1149 

The Medgen Information Management Department maintains inpatient, outpatient surgery (ASU), and emergency records. We have access to some types of outpatient test results. We do not maintain radiology films, cardiac videos, pathology slides, or outpatient MRI test results or film. Requests for that type of information must be directed to the specific departments where the test occurred. Phone numbers for all departments are available on this website.

In accordance to St. Mary Medical Center Policies, patient information is faxed ONLY for immediate and emergent patient care to healthcare providers or healthcare facilities.

State regulated fees for photocopies are charged to all requesters EXCEPT physicians and other healthcare facilities who need the records for patient care. The fee schedule is available upon request.


Please be advised that each time photocopies of patient information are released to any requester, the following disclosures are sent with the copies:

  • This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom is pertains or as otherwise permitted by 42 CFR Part 2.
  • This information has been disclosed to you from state records whose confidentiality is protected by state statute. State regulations limit your right to make any further disclosure of this information without prior consent of the person to whom it pertains.
  • This information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is authorized by the Confidentiality of the HIV-Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.

The Correspondence Coordinator or representative is available to answer your questions by calling 949-478-0051  during normal business hours.

We appreciate the opportunity to serve you.