Complete the entire form, taking note of the following information:
- Examples include continuing care, insurance, attorney, personal use or other.
- Patient name:
- Name used during the hospital visit.
- 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.
- 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 forms to:
Chilton Medical Center
Attn: Health Information Management
97 West Parkway
Pompton Plains, NJ 07444
Hackettstown Medical Center
Attn: Medical Records
651 Willow Grove Street
Hackettstown, NJ 07840
Morristown Medical Center
Attention: Medical Records Box #22
100 Madison Avenue
Morristown, NJ 07960
Newton Medical Center
Attention: Health Information Management Department
175 High Street
Newton, NJ 07860
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 for 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)
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.
MyChart Patient Portal
Atlantic Health System offers MyChart, an interactive health management tool that gives patients 24/7 access to portions of their electronic medical record.
It enables you to securely use the internet to help manage and receive information about your health, including the ability to view test results, communicate with your doctor, manage appointments and more.