Three Ways of Obtaining Medical Record Request Form

1. Download and print form
2. Call SMMC Health Information Department 973-877-5115 to have Medical Record Request form emailed, faxed, or mailed to you
3. Pick up form in Main Lobby of SMMC

Complete Medical Record Request Form and Send Request to:

Mail request to:

Fax request to: 973-877-5112

Drop off completed form in Main Lobby of SMMC

Options to Obtain Medical Records

Please remember to check an option in the box on the top right side of the form telling us how you would like to receive your medical records. Example:

• Authorized person will pick up
• Mail to Authorized person
• Fax to Authorized person

1. If you choose – Authorized person will pick up:
   1. The hours for medical record pick up:
      1. Health Information Management, Monday-Friday 8 a.m. to 4:30 p.m.
      2. Release of Information (ROI), Monday-Friday 8 a.m. to 4 p.m.
   2. Location for pick up is Saint Michael’s Medical Center’s Main Lobby desk.
   3. Authorized person must show valid picture I.D. (driver’s license, passport)
   4. Authorized person’s I.D. must match the Authorized person listed on the Medical Record Request Form
   5. Authorized person will sign Release Form provided by SMMC
2. If you choose – Mail to Authorized person
   1. Please check to make sure the address is correct on the Medical Record Request Form.
3. If you choose – Fax to Authorized person
   1. Please make sure the Fax number is correct on the Medical Record Request Form.

If you should have any further questions or problems, please contact the HIM Department at 973-877-5115.

Thank you for your understanding during this time.
HIM Manager