Health Information Management

One destination for everydimension of your health.

Whether you’re switching providers, applying for insurance, supporting a legal matter, or just want a copy for your own files — we’ll get you what you need. HIPAA-compliant, secure, and processed within 30 days as required by New Jersey law.

At a Glance

The Madison Standard

We process every records request through a single Health Information Management (HIM) workflow — supervised by our Privacy Officer — so nothing falls through the cracks and everything meets HIPAA & NJ N.J.A.C. 13:35-6.5

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Start Here

Who's making
this request?

The path is different depending on whether the records are for you, for someone you legally represent, or for a third party (insurance company, attorney, another provider). Pick the one that fits.

PATH 01

I'M THE PATIENT

You're requesting your own medical records — for personal files, a new provider, life insurance, or any other reason you don't have to disclose.

YOU'LL NEED

  • Government-issued photo ID
  • Date(s) of service requested
  • Preferred delivery method
BEGIN MY REQUEST →

PATH 02

I'M A LEGAL REPRESENTATIVE

You're a parent of a minor, legal guardian, healthcare proxy, executor, or hold a power of attorney for the patient.

YOU'LL NEED

  • Your photo ID + patient's info
  • Proof of legal authority (POA, court order, etc.)
  • For minors: birth certificate or custody order
BEGIN AUTHORIZED REQUEST →

PATH 03

I'M A THIRD PARTY

Attorney, insurance carrier, automobile/workers' comp carrier, or another provider requesting on behalf of the patient.

YOU'LL NEED

  • Patient-signed HIPAA authorization
  • Subpoena or court order if applicable
  • Letter of representation on letterhead
SUBMIT THIRD-PARTY REQUEST →
How It Works

From request submitted
to records in your hands.

01

Submit

Complete the form below or download the printable PDF. Upload your ID and supporting documents securely.

02

Verify

Our HIM team reviews your request, verifies your identity, and confirms the scope of records authorized for release.

03

Process

Records are pulled, reviewed for completeness, and prepared in your chosen delivery format (secure portal, encrypted email, or mail).

04

Deliver

You receive your records within 30 days — most requests are completed in 7–14 business days. Fee invoice (if applicable) sent separately.

HIPAA Authorization

Records Request &
Release Authorization.

All fields marked with a red asterisk (*) are required. Your information is encrypted in transit and reviewed only by authorized HIMS staff.

Authorization for Release of Protected Health Information. Madison Medical Sports & Wellness, 345 Main Street, Madison, NJ 07940.

1. Patient Information

MM slash DD slash YYYY
For identity verification only

2. Requestor Type

Requestor Type(Required)

3. Records Requested

MM slash DD slash YYYY
MM slash DD slash YYYY
Record Types Requested(Required)
Leave blank if you want records from all providers.

4. Delivery Method & Recipient

Delivery Method(Required)

5. Required Document Uploads

Required Document Checklist
Check the documents that apply to your request. After submitting, you will receive a confirmation email with a secure upload link. Documents may also be brought in person to the office.

Upload instructions: After submitting this form, you will receive a confirmation email with a secure upload link. Documents may also be brought in person to our office.

6. Patient Attestation & Signature

By signing below, I certify that the information provided is true and accurate, and I authorize Madison Medical Sports & Wellness to release the records described above to the recipient(s) specified.

I understand that:

  • This authorization is valid for 12 months from the date signed unless revoked earlier in writing.
  • I have the right to revoke this authorization at any time, except to the extent action has already been taken.
  • Records released to non-healthcare entities may no longer be protected by HIPAA.
  • Madison Medical may charge a reasonable fee per N.J.A.C. 13:35-6.5, maximum $1.00 per page or $100 per record, whichever is less.
  • I do not have to sign this form to receive treatment, and treatment cannot be conditioned on signing.
MM slash DD slash YYYY
Fee Schedule

Transparent fees,
set by New Jersey law.

Per N.J.A.C. 13:35-6.5, the maximum fees a healthcare professional in New Jersey may charge for medical records are listed below. We follow these limits exactly — no service fees, no markups.

TYPE OF REQUEST
WHAT'S INCLUDED
FEE
Patient Portal Access
Self-service download of all records available in your portal
FREE
Patient or Legal Rep — Standard Records (under 10 pages)
Complete or partial record, paper or electronic
$10 flat
Patient or Legal Rep — Standard Records (10+ pages)
Complete or partial record, paper or electronic
$1.00 / page · max $100
Patient — Billing Records
Itemized statements, billing history
FREE
Authorized Third Party (Attorney, Insurance, etc.)
Same record types, third-party request
$1.00 / page
Search Fee (third-party only)
Applies even if no records are found
$10 / request
Imaging on CD/DVD
X-rays, MRI, DEXA, etc.
$30 / disc + $10 admin
Certified Copy
Notarized certification of authenticity
$10 / certification
Postage
Tracked USPS mailing
Actual cost

Financial Hardship Policy

Madison Medical waives records fees for patients who demonstrate financial hardship — this includes patients at or below 250% of the federal poverty level, or those enrolled in Medicaid, NJ FamilyCare, SNAP, SSI, WIC, or similar assistance programs.

Mention this on your request, or check the financial hardship box in the form above. No additional documentation is required beyond standard ID verification.

Patient Rights

You have more rights
than most providers tell you
about.

Under HIPAA and New Jersey law, every patient has the following rights regarding their medical records. We list them here because you should know them — even when other providers don’t make them obvious.

RIGHT 01

Access to Your Records

You have the right to request and receive a copy of your medical records — typically within 30 days. We'll deliver them in the format you request when feasible.

RIGHT 02

Right to Amend or Correct

If you believe something in your record is incorrect or incomplete, you have the right to request an amendment. We'll respond within 60 days. Even if denied, your written disagreement becomes part of the record.

RIGHT 03

Accounting of Disclosures

You can request a list of disclosures we've made of your protected health information for the past six years (excluding standard treatment, payment, and operations).

RIGHT 04

Right to Restrict Disclosures

You may request that we limit how we use or share your information — particularly with health plans for services you've paid for out-of-pocket in full. We're legally required to honor that specific request.

RIGHT 05

Confidential Communications

You can ask us to communicate with you in a specific way (only by phone, only at a certain address, etc.) to protect your privacy. We'll accommodate reasonable requests.

RIGHT 06

File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health & Human Services Office for Civil Rights. We will not retaliate.

Common Questions

Things people always ask
but rarely get answered
clearly.

Per N.J.A.C. 13:35-6.5, the maximum fees a healthcare professional in New Jersey may charge for medical records are listed below. We follow these limits exactly — no service fees, no markups.

How fast will I actually receive my records?

By law, we have up to 30 days to fulfill a complete records request. In practice, most patient requests are completed in 7–14 business days. Records already available in your patient portal are accessible immediately. If your request requires pulling external records (imaging from another facility, for example), the turnaround may be at the longer end.

Can I get my records without paying anything?

Yes, in several situations:

  • Records available through your patient portal are always free.
  • Billing records are free to patients and legal representatives.
  • If your records are being sent to another treating provider for continuity of care, no fee is charged.
  • Patients who qualify under our Financial Hardship Policy (Medicaid, SNAP, SSI, etc.) are not charged.
What if I need my records faster — for a specialist appointment, surgery, or court date?

Note your deadline in the “Additional Instructions” field of the form. For genuinely urgent clinical situations, call the office at (973) 966-1111 and ask to speak with our HIM team. For records being transferred directly to another provider, we can usually fax or securely transmit them within 24–48 hours.

Are psychotherapy notes included?

Psychotherapy notes — meaning a therapist’s personal process notes kept separately from the rest of the chart — require a separate, specific authorization under HIPAA. If you need these, indicate so explicitly on your form. Standard mental health treatment summaries, diagnoses, medication lists, and visit notes are part of your regular medical record and are released through this same process.

What about records from other providers that are in my chart?

Records that other providers sent to us (consultation reports, outside lab results, prior imaging) become part of your Madison Medical chart and are released to you on request, the same as our own documentation. However, we cannot release records that originated elsewhere directly back to a third party — those should be requested from the original source.

I want to correct something I think is wrong in my record. How?

You have the right to request an amendment. Submit a written request to our Privacy Officer (contact info below) describing what you believe is incorrect and what you’d like changed. We’ll respond within 60 days. If we agree, we’ll amend the record. If we disagree, you may submit a statement of disagreement that becomes a permanent part of your file. Either way, your input is documented.

How long does Madison Medical keep records?

Per New Jersey regulation, we retain adult medical records for a minimum of seven years from the date of last entry. Records for minors are retained for at least seven years past the age of majority (i.e., until the patient turns 25). After the retention period, records are destroyed using HIPAA-compliant methods (shredding, secure digital destruction) — they cannot simply be requested back.

I'm a parent — can I get my child's records?

Generally, yes — for children under 18, a parent or legal guardian can request the records. Exceptions exist for sensitive services a minor may have legally obtained on their own (such as reproductive health, mental health treatment, or substance use treatment in certain circumstances under New Jersey law). In these cases, the minor’s separate consent may be required.

I'm an attorney requesting records for a client. What do you need?

Submit through Path 03 (Third Party) and provide:

  • A current HIPAA-compliant authorization signed by your client (within the last 12 months)
  • A letter of representation on firm letterhead
  • A subpoena, court order, or other legal process if applicable

Third-party requests are billed at $1.00 per page plus a $10 search fee. Invoices are sent prior to release.

Is the form on this page actually secure?

Yes. All form submissions are transmitted over encrypted HTTPS, stored on a HIPAA-compliant server, and accessed only by authorized HIM staff. Document uploads use a separate secure portal that meets HIPAA’s technical safeguards. We never request your full Social Security number, financial account information, or driver’s license number through this page — only the last 4 digits of SSN, which is used solely for identity verification.

▎ Health Information Mgmt

HIM Department

For records requests, status inquiries, and authorization questions.

(973) 966-1111
records@madisonmedicalnj.com
▎ Privacy Officer

HIPAA & Compliance

For complaints, amendment requests, and rights inquiries.

privacy@madisonmedicalnj.com
345 Main Street
Madison, NJ 07940
▎ Office for Civil Rights

File a Federal Complaint

If you believe your privacy rights were violated, you may file directly with HHS.

hhs.gov/ocr
1-800-368-1019