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Updates

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.

As of April 14, 2025 Primary Care – Voorhees has relocated to 165 S Black Horse Pike, Runnemede.

As of April 14, 2025  Pediatrics – Manasquan has relocated to  3350 State Route 138 Wall.

As of April 7, 2025, Podiatry in Bayonne has relocated to 191 Lefante Way, Suite C in Bayonne.

As of April 7, 2025  Gastroenterology – Hackensack and Cardiology – Hackensack have relocated to 1 Maywood Avenue in Maywood.

As of April 7, 2025 Primary Care – Moorestown and Cardiology – Moorestown have relocated to Cherry Hill at 322 Route 38, Cherry Hill.

As of April 7,  2025,  Primary Care – Secaucus  and Gastroenterology – Secaucus have relocated to Rutherford at 201 Route 17 11th Floor Rutherford.

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

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Extended Hours in Lake Success  will be closed on Sunday, May 11, Sunday, May 25, and Monday, May 26.

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

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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