request medical records from Good Samaritan Regional Medical Center

Medical Records Request Form (PDF) or (Microsoft Word). 

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 $0.75 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)

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