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Medical Records

Obtaining Copies of Medical Records

The Medical Records department is responsible for managing requests and releasing medical records. Due to the confidential nature of a patient's medical record, Holy Name Medical Center requires all requests for release of medical records be accompanied by a completed authorization form and signed by the patient. The following steps are designed to best explain the process in order to help expedite your request as quickly as possible.

When completing an Authorization for Release of Medical Information Form.

The following information must be included:
  • Who the records are being furnished to - including address and phone number
  • Demographic information of the patient
  • Nature of information to be released
  • Dates of treatment
  • Purpose for release
  • Patient signature
Due to HIPAA regulations, your request will be returned to you and not be completed if any of the required information above is missing from the authorization form.

If you are a Power of Attorney, Executor of the Estate, or Administrator of the Estate, please sign and indicate this authority. A copy of this legal document granting you this authority must be included or we will be prohibited from processing your request.

Note: Please remember to sign and date the form.
How to Submit Your Request
  • By Mail:
    Holy Name Medical Center
    Attn: Medical Records Dept
    718 Teaneck Road
    Teaneck, NJ 07666
  • In Person:
    You can drop it off at the Health Information Services department at the Medical Center.

    Hours of operation:
    Monday through Friday (except for major holidays)
    8:00 AM to 5:00 PM
  • By Fax:
    You can fax the form to us at (201) 833-7138.
HIPAA regulations allow a healthcare entity up to 30 days to process copy requests for medical records. We generally complete requests prior to the allotted time permitted, but due to the possibility for a heavy volume of requests received, we cannot guarantee a specific date prior to the 30 days. Additionally, regulations set forth by the New Jersey Department of Health stipulate that a charge may be incurred by those requesting medical records.

Note: Please refer to the "Copy Fees" tab for a list of associated charges.

To inquire on the status of a request, please contact a Correspondence Specialist at (201) 833-7044.
Fee Schedule for Copies of Medical Records
(As approved by NJ Department of Health and Senior Services)

Direct release to: Cost:
Physicians No Charge
Mental Health Centers No Charge
Clinics No Charge
Hospitals No Charge
Patient or Legally Authorized Representative - $1.00 per page
- $0.25 per page in excess of first 100 pages
- No search fee
- Maximum charge per admission is $200

Attorneys, Insurance Companies:

Search Fee $10.00
Viewing $20.00
Abstract * - $10.00 search fee
- $1.00 per page
First 100 pages $1.00 per page
Each additional page
(In excess of the first 100 pages, up to a maximum of $200.00 for each admission)
$0.25 per page
Emergency Room Records - $10.00 search fee
- $1.00 per page
Postage Charge (not to exceed $5.00) Actual Cost


New Jersey $2.00
Out of state (with patient authorization) $15.00

* Abstract = Face sheet, History & Physical, Discharge Summary, Consultation, Operative Report, Pathology Report, Emergency Room Record