To request your medical records, please print and fill out the authorization form below and return to Lewistown Hospital.
Completed Authorization Forms should be returned to Lewistown Hospital:
Health Information Management
400 Highland Avenue
Lewistown, PA 17044
Forms can also be returned in person to the Health Information Management Department located on the Fourth Floor of Lewistown Hospital, Room 4202.
Instructions for completing "Authorization to Use or Disclose Health Information" form:
- Please complete entire form leaving no blanks.
- Form would be used for releasing your medical records to other hospitals, physicians, insurance companies, and attorneys.
- There is a fee for copying medical records for attorneys, insurance companies, and for personal use.
- There is no fee for copying medical records for continued care - such as another hospital and/or physician.
- Both pages of form must be returned.
If you have any questions regarding this form, please contact Health Information Management Department at (717) 242-7252.