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CalendarEffective March 1, 2025: Former patients of CareMount Medical and Crystal Run Healthcare, powered by Optum will have access to all features of the MyChart patient portal.

We have transitioned to a new electronic health record system to better serve you. During this time, you may experience some delays. We apologize for any inconvenience and thank you for your patience.

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As of April 7, 2025,  Primary Care – Secaucus will relocate to Rutherford at 201 Route 17, Floor 11, Suite 1102.

As of March 31, 2025, Primary Care – Rutherford will relocate to 201 Route 17, Suite 1102 in Rutherford.

As of March 28, 2025,  Primary Care – Roslyn will relocate to the Optum multi-specialty medical office location in Lake Success.

As of March 3, 2025, Pediatrics – Port Jefferson has relocated to 1500 Route 112, Building 1, Floor 1, in Port Jefferson.

As of March 3, 2025, Primary Care – Port Jefferson Station has relocated to 1500 Route 112, Building 1, Floor 1, in Port Jefferson.

As of February 24th, 2025, Dermatology – Port Jefferson Station has relocated to 1500 Route 112, Building 1, Floor 2, in Port Jefferson.

As of February 24, 2025, Pediatrics – Bedford Hills office has relocated to Pediatrics – Mount Kisco.

As of February 24, 2025, Dr. Gaurang Trivedi has relocated his practice to 110 South Bedford Road Mount Kisco.

Recording/Photography Not Permitted on Premises

Office and Urgent Care Closures

The Croton-on-Hudson lab is temporarily closed until further notice.

COVID-19 Information and Updates

Flu and COVID-19 vaccines are now available ›

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Home ❯ Helpful Resources ❯ Medical records request forms – New York

Medical records request forms – New York

Medical records request forms – New Yorkformer ProHEALTH

Patients can view their Protected Health Information (PHI) through the MyChart patient portal. If the information isn’t available in MyChart, patients can submit a request for their records online using the Patient Medical Records Request Tool.

Patient online records request
Provider online records request

Printable Release of Information (ROI) forms are also available in English and Spanish for patients who do not wish to make use of the online options.

Forms submitted with incomplete or unreadable information, insufficient legal authority, or signed by the incorrect individual may result in processing delays. If you are using this form for another individual (patient), you can complete the Release of Information form.

If you are not the patient, but an authorized representative by law, you will need to provide supporting documentation showing this, when submitting the completed form.

Optum may impose a reasonable, cost-based fee for a copy of your PHI, as permitted by the HIPAA Privacy Rule and state law.

Return the completed form using one of the options listed below:
  • Email: [email protected]
    Email is not a secure method of communication and carries some risk of being read by a third party. Be advised, that all outbound electronic transmission of medical records are performed via secure transmit
  • Fax: 1-516-812-4305
  • Mail: Optum Medical Care, New York (FKA ProHEALTH)
    Health Information Management Department
    3 Delaware Drive, Suite 206
    Lake Success, NY 11042