One Goal. One Passion. Every Patient. Every Time.

Health Information Management

To request a copy of a medical record from University Hospital’s Health Information Management (Medical Records) department, begin by printing a HIPAA-compliant authorization form – available in English or en Espanol.

Complete the entire form, taking note of the following information:

Patient name: Name used during the hospital stay/visit.

Date of birth: To verify the accuracy of patient's identity.

Treatment dates: Be as specific as possible regarding the date services were received by the patient.

Signature: Patient must sign the form unless he/she is a minor or the requestor is the authorized legal guardian, health care agent, or other personal representative. A copy of legal documentation must accompany the request.

Mail the completed form to:
University Hospital
150 Bergen Street
Medical Record Correspondence, Room B417
Newark, NJ 07103


Once the form is received, an invoice for the associated fee or a status letter will be sent to the requestor’s address. There is no charge for your record if it is faxed or mailed to a physician’s office or health care facility, however, personal copies are charged the following fees:

  • $10 processing fee (one-time fee per request)
  • $1 per page for the first 100 pages (fee per admission/encounter)
  • $0.25 per page up to a $200 maximum (fee per admission/encounter)

If your request requires a fee, please send payment as soon as possible to the department. Upon receipt, the medical record copy will be available for pick up or mailed within 30 days.

Business hours: 8:30 am – 4:30 pm Monday through Friday

For additional information, contact the Health Information Management (Medical Records) department at 973-972-5608.