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For Patients


Request medical records from Bon Secours Community Hospital

To request medical records from Bon Secours Community Hospital you will need to submit a signed Authorization for Release of Patient Health Information form to the Health Information Management (HIM) Department.

You can download the Authorization for Release of Patient Health Information form below and submit this authorization to the HIM Department.

Medical Record requests are usually processed within 7-10 business days.

A photo ID is required when picking up your requested information.

fees

If the information to be released is sent to a physician, hospital or other medical provider, there will be no charge for the records. For records sent elsewhere (ex. for yourself, attorney, etc.) there will be a fee of $.36 cents for each page copied.

Mailing Address Bon Secours Community Hospital
HIM Department
160 East Main Street
Port Jervis, NY 12771
P: 845-858-7092
F: 845-858-7408
HIM Department Business Hours: Mon – Friday 7:00 a.m. – 4:00 p.m.

Download the Authorization for Release of Patient Health Information Form

Request medical records from Good Samaritan Hospital

Medical Records Request Form

The Health Information Management Services (HIMS)

The Health Information Management Services Department is responsible for organization, storage and retrieval of patient records.

You may call our correspondence secretary at 845.368.5000 ext. 6249, Monday through Friday 9 am to 5 pm, or fax an authorization to 845.368.5346 for copies of your records.  You will be required to sign an authorization before the records will be released.  Identification is required.

  • In the case of a mental or incompetent patient, or the death of an adult, the executor or administrator of the estate or the guardian of the incompetent who presents proper credentials from court signs the authorization for release of privileged information. If there is no such fiduciary appointed, then the next of kin may sign the authorization.
  • Minors, as defined by New York State, are individuals under the age of 18. A parent or legal guardian must authorize the release of privileged information on the record of a minor. Emancipated minors may sign for release of their own information. An emancipated minor is any person under the age of 21 who is living apart from his/her parents and makes his/her own living, or a minor who is married.

If the records are for your own use, there is a charge of $0.36 per page.  You will be sent a pre-bill from our copy service company (845-368-5000 ext. 6254) for the copying of records.

If you are writing or faxing an authorization, please send it to the attention of HIMS correspondence secretary and include the following information:

  • Name
  • Date of birth
  • Phone number
  • Date(s) of service
  • Where copies are to be sent (name, phone, address)
  • Reason for copies
  • When copies are needed
  • Your signature is required

Response to authorizations will be within 10 days of receipt, as required by NYS law.

birth certificates

The hospital birth registrar (845.368.5000 ext. 6253) compiles the newborn information and forwards this information to the Village of Suffern who issues the birth certificate. The hospital does not have access to birth certificates. Copies of birth certificates can be requested from the Village of Suffern at 845.357.2600 (a charge for the copy may apply)

Request medical records from St. Anthony Community Hospital

Medical Records Request Form

The Medical Records Department is responsible for the organization, storage and retrieval of all patient medical records.

If you require records, please call our correspondence secretary at 845.987.5193, Monday through Friday from 8 a.m to 4 p.m. You will be required to sign an authorization before records will be released. In some cases, identification is required. If the records are for your own use, there is a charge of $0.36 per page.

When requesting medical records, it is helpful if you have the following information when you call or visit the Medical Records Department:

  • Name of patient
  • Address of patient
  • Phone nNumber
  • Date of birth
  • Date(s) of service
  • Where service performed (what hospital department)
  • Reason for copies
  • When copies are needed
  • Where copies are to be sent
  • The Medical Records Department is located on the basement level of the hospital