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Important Alerts
Updates

Effective June 2, 2025, Optum Cardiology and Optum Cardiac Electrophysiology will be relocating to the 100 building on South Bedford Road, on the 3rd Floor. The new suite is just a two-minute walk away.

Effective May 28, 2025, Pediatrics in West Orange located at 35 Park Ave will be relocating to  55 Morris Ave in Springfield.

As of May 19, the OBGYN office in Syosset has relocated to Suite 181 in the same building at 575 Underhill Blvd, Syosset, NY.

As of May 5, 2025, Podiatry in West New York has relocated to 201 State Rt 17 in Rutherford.

As of April 28, 2025, Primary Care in Haddon Heights has relocated to 2 South Black Horse Pike in Mt. Ephraim.

As of April 28, 2025, Cardiology in Haddon Heights has relocated to 322 Route 38, Cherry Hill.

As of  April 21, 2025 Pediatrics – Wall at 1560 State Route 138 has relocated to 3350 State Route 138.

Recording/Photography Not Permitted on Premises

Office and Urgent Care Closures

Extended Hours in Lake Success  will be closed on Sunday, May 25, Monday, May 26 and Tuesday, May 27..

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