How to Request Your Medical Records

Patient Access Form - English (PDF)

Patient Access Form - Espanol (PDF)

Used when an individual requests a copy of his/her own medical record; or to send the record to a third party

PHI Change Request Form

Used when an individual requests a change and/or preferences to their PHI.

Authorization to Disclose - English (PDF)

Authorization to Disclose - Spanish (PDF)

Used when an individual requests that we release information to a third party and it contains sensitive data (mental health, substance use or HIV/AIDS).  This form contains a provisions that prohibits re-disclosure by the recipient

Request must be signed by the person who the records belong to, or by a LEGALLY authorized person.

Records will be mailed to a physician or other healthcare facility for free. Please provide the telephone number or address so they can be sent promptly.

If you are requesting your records and they are not being mailed by us to a physician or healthcare facility there is a $00.15 per page charge (up to 100 pages & $0.25 per page after that) please keep this charge in mind when requesting a complete chart, as this can get very expensive. A discharge summary often gives a satisfactory overview of the course of the hospital stay that is longer than 72 hours, stays less then 72 hours discharge instruction will be available.

Please bring or mail your completed form to:

AtlantiCare Regional Medical Center-City Campus 
1925 Pacific Avenue 
Atlantic City, NJ 08401 
Attn: Health Information Mgmt.

When your records have been processed, an invoice will be mailed to you and when payment has been submitted, the records will be sent out by mail.

OR Please email your completed request to HIMROI@atlanticare.org