Medical Records

Medical Records Request Form

To submit a new request for therapy records or psychiatry records for care provided at the Center for the Treatment and Study of Anxiety, please complete the Medical Records Request Form and scan it (or photograph it in high resolution) and email it back to us at Tiona.Combs@pennmedicine.upenn.edu. Please follow the instructions below to ensure proper completion of the form:

• In the section titled "I am requesting my protected health information (PHI) from":
  • Check CPUP/CCA Outpatient Practice
  • Then write in CTSA or COTTAGe (depending on which clinic you were seen in)
• In the section titled "I request my PHI to be released to":
  • Complete the name/address/fax # for who you want the record released to
  • For example, records can be released to yourself, a law firm, another doctor, school, etc.
• If you would like the typical set of psychology notes that we keep, in the section titled "I authorize the following PHI to be released from my medical records":
  • Check Clinic/Progress Notes, Itemized Billing Record, Medication Record (if you were seen by our psychiatrist), and Other: then write in Psychiatric Evaluation
• In the section titled "Behavioral Health Visits"
  • Check Yes
• Complete the "Purpose of requesting information" and "Delivery Method" sections
• Sign your name, print your name, and date the document
• Email the document to Tiona.Combs@pennmedicine.upenn.edu