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	Dr. David Shulkin
	Dr. Chris Magovern

	Morristown Medical Center
	Overlook Medical Center
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	Goryeb Children's Hospital

	Morristown Medical Center
	Overlook Medical Center
	Newton Medical Center
	Goryeb Children's Hospital

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Medical Records and Radiology Images

To request a copy of a medical record or radiology images from Overlook Medical Center's Health Record Services Department, begin by printing a HIPAA-compliant authorization form – available in English or Spanish.

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: We 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 Medical
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, you are charged the following fees personal copies:

$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)
$15 per CD for radiology images (multiple studies can be burned onto one CD)

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.