Health Records

To request a copy of a medical record from Overlook Hospital's Health Record Services Department, begin by printing a HIPAA-compliant authorization form – available in English or en Espanol.

Complete the entire form, taking note of the following information:

• Purpose: examples include – continuing care, insurance, attorney, personal use or other
  
  
• Patient name: name used during the hospital visit
  
  
• Phone: Overlook Hospital's Health Record Services Department may need to contact this number in case of questions or clarifications
  
  
• Date of birth: helps determine accurate patient identification
  
  
• Treatment dates needed: be as specific as possible regarding the date services were received by the patient
  
  
• Specified reports: check all that apply to the treatment dates requested
  
  
• Released to: examples include – patient, authorized personnel, physician office or lawyer; be sure to include the address or fax number and mark in the provided boxes if the record will be picked up or mailed
  
  
• Special instructions: examples include – call when records are ready for pick up, fax records, list appointment date, call with invoice amount or other
  
  
• Signature: patient must sign the form unless he or she is a minor or the requestor is the authorized legal guardian, health care agent or other personal representative; a copy of legal documentation must accompany the request
  

Mail or fax the completed form to:
Overlook Hospital
Attention: Health Record Services/ROI
99 Beauvoir Avenue
Summit, NJ 07901

Once the form is received, an invoice for the associated fee or a status letter will be sent to the requestor’s address. There is no charge for your record if it is faxed or mailed to a physician’s office or health care facility, however, personal copies are charged the following fees:

• $10 processing fee (one-time fee per request)
• $1 per page for the first 100 pages (fee per encounter)
• $0.25 per page for an additional 200 pages (fee per encounter)
  

If your request requires a fee, please send payment as soon as possible to the department. Upon receipt, the medical record copy will be available for pick up or mailed within 30 days.