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Medical Records

Obtaining Copies of Medical Records

The Health Information Management Services (Medical Records) Department is responsible for managing requests and releasing copies of medical records. Due to the confidential nature of a patient's medical record, Holy Name Medical Center requires ALL requests for the release of medical records be accompanied by a completed, HIPAA-compliant, Authorization for Release of Medical Information Form, signed by the patient or legal representative.

When completing an Authorization for Release of Medical Information Form.

The following information MUST be included:
  • Who the records are being furnished to? Include the person's name, complete address, (department, room or suite number if applicable), and phone number.
  • Demographic information of the patient. Include any aliases, married name, and date of birth.
  • Nature of information to be released. Check the specific information requested, which is located under part 1 on the Authorization for Release of Medical Information Form.
  • Dates of treatment. Enter the date range, which is located under part 2 on the Authorization for Release of Medical Information Form.
  • Purpose for release. MUST be completed, which is located under part 3 on the Authorization for Release of Medical Information Form.
  • Patient's signature. The signature of the patient or Legal Representative MUST BE NOTARIZED if not signed in person in the HIM Department. A copy of the legal paperwork (Health Care Proxy, Letters of Administration, Guardianship, etc) MUST accompany the request, if not sign by the patient.
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.
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 4:30 PM

    Note: A Photo I.D. is required at the time of your request.
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 $0.36 per page

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