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Insurance Plans

Health Information Management

Health Information Management (HIM) / Medical Records Department Policies

Community Council Health Systems (CCHS) is committed to protecting your privacy. Our staff treats your medical records’ information in compliance with federal and state requirements.

Obtaining Medical Records

Requests for medical records may be made by returning an Authorization to Release or Obtain Confidential Health Information form via mail, fax to 215-473-5961, or attaching below.

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

The Authorization to Release or Obtain Confidential Health Information form for patients under the age of 13 must be completed by a parent or legal guardian.


In order to protect your privacy, we require written authorization to release your medical records to another person or organization. Below is the Authorization to Release or Obtain Confidential Health Information form, which you can print, fill out, and return to the HIM /Medical Records Department. Please allow two to three business days for processing.






If you believe your Privacy Rights have been violated, you may submit your complaint in writing to the attention of the CCHS’ Privacy Officer. Call the Privacy Hotline at (833) 732-CCHS (2247) or telephone the HIM department. The quality of your care will not be jeopardized, nor will you be penalized for filing a complaint. Your feedback allows us to improve our services.


HIM Contact Information

If you have questions regarding request for copies of medical records, please contact the Health Information Management (HIM) /Medical Records Department at: 

  • Complete release of information (ROI) and submit with Medical Records Request form below.

  • Phone: 215-473-7033 Extension 7121   Business hours are 9 a.m. to 4:30 p.m., Monday through Friday.

  • Email:

  • Fax: 215-473-5961 (We only accept a legible fax from healthcare providers.)

  • Mail: You can also mail your correspondence to:

Community Council Health Systems

Attention: Health Information Management Department

4900 Wyalusing Avenue

Philadelphia, PA 19131

Confidentiality Bulletin

August 21, 2023



The intent of this bulletin is to reiterate the importance of Confidentiality of Mental Health Records. As CCHS employees, we are bound by federal/state laws and ethical standards to maintain the confidentiality of participants Protected Health Information (PHI). PHI is individually identifiable health information in any form:  oral, electronic, written.


Disclosure of Health Information

Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy and security of individual health information. An individual has the right to keep their health information private. Thus, we are all obligated to safeguard all participants’ Protected Health Information (PHI).   CCHS employees are prohibited from disclosing an individual’s health information without a written authorization from an individual or parent/legal guardian (except under limited circumstances). This includes disclosure/communication of health information to external entities in any format (orally, electronically or written). If an external entity is requesting confidential information of an individual, a formal request along with a valid Release of Information (ROI) form must be forwarded to CCHS Medical Records/ HIM Dept.


Release Without Signed Authorization

Information may be released without signed authorization only in the following instances:

  1. To those currently providing treatment to the consumer, to the extent that they need the information to provide proper emergency care and treatment (55P.S. 7111; 55 PA code 5100.32(a) (1).


  1. To persons and treatment programs or facilities where the consumer is referred for emergency care: a summary or some of the portion of the treatment information is necessary for the provider to assess the consumer’s needs and to assure continuity of proper care and treatment.  55 PA Code 5100.32(a) (1).


  1. The Director of a County Office of Mental Health and Mental Retardation, or their designee: If the information is requested as part of an emergency psychiatric commitment process, i.e., a petition filed under sections 302, 303, 304, or 305 of the Mental Health Procedures Act (1976).  55P.S. 7101 et seq. 55 P.S. 7111; 55 PA Code 5100.32(a) (5).



  1. When a consumer confidential information is released to facilitate emergency care, a Significant Incident Report (SIR) must be completed and submitted to Compliance.


Breach of Confidentiality

Breach of confidentiality occurs when an individual’s confidential information is disclosed to a third party without his or her written consent. To avoid such violation, all CCHS employees must adhere to this Confidentiality Bulletin. We all have the duty to maintain the confidentiality of individuals’ health information who we service. Failure to comply can result in employment termination and /or civil /criminal penalties.


ALL requests for the release of participants’ service record (COS Wellness, IBHS,

Recovery Paths, Mobile Support Services, Non-Fidelity Act and Children Blended Case Management), is managed only by the Medical Records Coordinator (MRC) and MR staff.  Please make certain you email or fax your completed Release of Information form to or fax attention Medical Records at 215.473.5961.   


Any questions you should contact Courtney Gibson, MR Coordinator at 215.473.7033 extension 7121, or 267.916. 1923 (cell).  You may also contact Wanda Moore Chief Compliance Officer, at 215.620.2707 or


Click the PDF icon
to download
the CCHS ROI form.
Medical Records Request
If request is for a child under the age of 14, is there a custody agreement in-place?
Are you the custodial parent/guardian?

Upload Completed Release of Information here

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Related reproduction fees


In accordance with PA state law, the following fees* are charged when providing copies of medical records. 

Per page charge, pages 1-20$1.70

Per page charge, pages 21-60$1.26

Per page charge, pages 61-end$0.44

Postage fees will also be added if records are mailed.

Flat fee for production of records to Support Social Security$31.94

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

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