Patient Records Request
If you are a patient seeking a copy of your Medical Records, please use this form. [PDF]
If you are a patient and would like your records sent to someone else, please use this form. [PDF]
If you are an agency, requesting records on behalf of a patient, please use this form. [PDF]
Send completed request forms to:
By Email: email@example.com or by Fax: 201-265-2364
Frequently Asked Questions
After completing a request form, where do I send it?
Requests can be emailed to firstname.lastname@example.org or faxed to 201-265-2364.
How long will it take to process my request?
While we make every effort to process all requests in a timely fashion, both the State of New Jersey and US HIPAA regulations grants us 30 days to respond to requests for medical records. If we are unable to complete your request within 30 days, we are required to notify you.
- Valid Authorization Required – fully and accurately complete the request form provided on this site.
- Requests for medical records must be specific or the request is deemed invalid.
- Unless otherwise specified, we will provide the most current records, i.e., 12 months.
- The individual timeline to collate all client records is dependent on the level of care, duration and intensity of a client’s treatment, the number of programs in which the client has been enrolled, and the time period covered by the requested records.
If I still have questions, who do I contact?
Email Patient Records at email@example.com