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To obtain a copy of a medical record, please print, complete and mail the medical record release form (available as PDF) or medical record release form Spanish (available as PDF) to the hospital.
You need Adobe Acrobat Reader installed on your computer to access the medical record release form.
click here.
Attn: Health Information Services
Monmouth Medical Center
200 Second Ave.
Long Branch, NJ 07740
If you are unable to print the attached form, you can send, fax or email. The letter should include the following:
- Patient Name
- Date of Birth
- Social Security Number
- Date of Hospitalization(s) (approximate date if actual unknown)
- Purpose of the request (who or what records are needed for)
- The name and address that records are to be released to
- Phone number where you can be removed.
- Specific medical record information being requested such as an Operative Report, Discharge Summary, etc. If you need the medical records for patient care, please request an abstract – which will include the appropriate information for another physician including all testing.
- Patient signature
If you are requesting medical records on behalf of an adult family member, the adult family member’s permission (signature) is required.
Requests for copies of medical records for continuing care to be sent directly to another healthcare provider are free of charge.
For all other requests, the charge for copies of medical records in accordance with the New Jersey Department of Health is $.48 per page - $200 maximum per record.
Attn: Health Information Services
Monmouth Medical Center
200 Second Ave.
Long Branch, NJ 07740
Fax: 732.923.7404
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