Medical Records Access

As a patient, you have a right to access to the information in your medical record. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), protects health information created or maintained by health care providers throughout the United States. Prior to receiving care in the hospital, each patient shall receive and be asked to acknowledge that they have received a Notice of Privacy Practices that explains their rights under HIPAA and the hospital’s use of their health information for treatment, payment, and health care operations without further authorization. Also, as part of the new regulations, each patient has the right, with some restrictions, to:

review his or her own medical record;

request an amendment or correction to the medical record;

add supplemental information to the record;

restrict use and disclosure of your medical information;

authorize formal consent before health information is released other than for treatment, payment, or as part of health care operations; and

know who requested and received medical information for other than treatment, payment, or health care operations.

In protecting your information, health care providers, such as Hackensack Meridian Health and their workforce, are prohibited, with some exceptions, from releasing your health information to anyone not involved in your health care or connected hospital operations, including family members, unless you have provided written consent. The Authorization for Release of Information form allows HMH to release your information to a particular agency or individual that you designate. To request access to or copies of your medical records or our authorization to release information form, please call one of the following telephone numbers:

Bayshore Medical Center: 732-739-5933 or 732-739-5985

Carrier Clinic: 908-281-1479

Hackensack University Medical Center: Joseph M. Sanzari Children’s Hospital: 551-996-2075

Jersey Shore University Medical Center / K. Hovnanian Children’s Hospital: 732-776-4241

Mountainside Medical Center: 973-429-6042

Ocean University Medical Center: 732-840-3331

Palisades Medical Center: 201-854-5081 or 201-854-5083

Pascack Valley Medical Center: 201-781-1116

Raritan Bay Medical Center: 732-324-5045

Old Bridge Medical Center: 732-324-5045

Riverview Medical Center: 732-530-2333

Southern Ocean Medical Center: 609-597-6011 x2121

Authorization of Release of Information

Request for Amendment of Information

Opt-Out Request

Care Everywhere and New Jersey Health Information Network are the health information exchanges that give health care providers outside the HMH network access to your health information that can be used for treatment purposes. This access to your health information gives providers an accurate and more efficient way to meet your health care needs. If you do not want any HMH facility or provider to share your health information outside of the HMH network, please complete this form. If you opt-out, you also have the right to opt back in at any time.

Patient's Information

First Name*

Last Name*

Date of Birth*

Address Line 1 *

Address Line 2

City*

State*

Zip Code *

Phone Number

Email*

Preference* Opt Out Opt In

Relationship to Patient *

Medical Records Access

Opt-Out Request

Patient's Information

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