Completing Your Authorization to Release Information Form

1. Click on one of the following links to print out the Authorization to Release Information form. English form or Español form.
2. Fill out the form in its entirety. Please be sure to include the patients name, date of birth, location that services took place, what records you are requesting and where you would like the information sent.
3. Sign and date the request and indicate your relationship to the patient at the bottom. Requests for psychological or psychiatric records on children over the age of 14 require the signature of both the patient and the parent/legal guardian. (An original signature is required, we do not accept electronic signatures)

*PLEASE NOTE: Leaving out any of the information listed above could delay the processing of your request.

• Once you have completed your request send it back to us for processing. Requests can be sent in the following ways:
  • Via fax to 908-301-5527 Attn: HIMS Department
  • Via email to: MedRecRequests@childrens-specialized.org
  • Via mail to:
    • Children’s Specialized Hospital
      150 New Providence Road
      Mountainside, NJ 07092
      ATTN: HIMS Department
  • Visiting the nearest HIMS department. There is a HIMS department in our Mountainside, Toms River & New Brunswick locations.

*PLEASE NOTE: Please allow extra processing time if you are requesting a large volume of records.

*Charges may apply for large volumes of records.