Patient Record Release Form
Please download the request for access form and follow the guidelines for completion.
(Get a Copy of Your Healthcare Information (Records))
Complete this form to request a copy of protected health information (PHI) maintained and used to make decisions about your treatment, including mental/behavioral health records that are maintained as part of your care by Riverside Medical Group a Part of Optum. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), this is called the Designated Record Set (DRS). Please complete each section of the form. 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, follow the guideline as below. Optum may impose a reasonable, cost-based fee for a copy of your PHI, as permitted by the HIPAA Privacy Rule and state law.
If you are requesting Access to Another Individual’s Records
Please have the patient sign the Authorization to Release Information Form
Authorization to Release Information form (English)
Authorization to Release Information form (Español)
Submit the completed form with your request if:
- You are not the legal representative, OR
- The patient is 12 or older, and the records may relate to sensitive health information, such as mental health, substance use, HIV/AIDs, STD, pregnancy, or reproductive health.
- If you qualify as a legal representative, you are required to attach supporting documentation:
- Power of attorney, Court Order, or another valid document
- HIPAA authorizations do not establish legal authority and are not sufficient to submit an access request through this process
Return the completed form using one of the options listed below:
- Email: [email protected]
- Fax: 551-257-7595
Mail: Riverside Medical Group HIM Department, 1 Harmon Plaza at 4th Floor Secaucus, NJ 07094