Request for Access to PHI

Patient Information

First Name

MI

Last Name

Date of Birth

Maiden or Other name

Medical Record Number

Email

Phone

Your Information

First Name

MI

Last Name

Email

Phone

Confirm Email

Confirm Phone

Mailing Address

Supporting Documentation

Your relationship to the Patient

Parent/Foster Parent

Guardian

Medical Power of Attorney

Executor of Estate

Document Upload

The facility has documented proof of my relationship to the patient on file i

I decline to upload supporting document(s) i

I will upload supporting documents(s) i

Upload supporting document(s) (Court Order or Medical Power of Attorney):

Authorization to release my medical records

I authorize

Hospital/Inpatient

NYP Allen Hospital

NYP/Columbia University Irving Medical Center

NYP Westchester i

NYP Lower Manhattan Hospital

NYP Morgan Stanley Children’s Hospital

NYP/Weill Cornell Medical Center

NYP Westchester Behavioral Health

NYP Brooklyn Methodist Hospital

NYP Hudson Valley Hospital

NYP Queens

Gracie Square Hospital

Outpatient/Provider(s) Offices/NYP Physician Medical Groups: For outpatient/physician office records only, please print provider(s) name(s):

Columbia University Irving Medical Center (CUIMC)

Weill Cornell Medicine (WCM):

NYP Medical Group Brooklyn:

NYP Medical Group Hudson Valley:

NYP Medical Group Queens:

NYP Medical Group Westchester:

Other

Other (Please print Name of Entity)

to disclose to

Me

or to

Named person or entity

A fee for medical record copies may apply. A patient whose records are copied and sent to another healthcare provider for the purposes of continuing to receive medical care does not pay a fee for medical record copies. Request for medical record copies for any use other than medical care may be subject to a fee. If a fee does apply, you will be notified prior to your request being processed. The HIPAA Privacy Rule permits healthcare providers to impose a reasonable, cost-based fee to an individual requesting a copy of medical records. The fee may only include the cost of labor, supplies and postage.

Name

Email

Phone

Fax

Mailing Address

Information to Release

What to Release (check all that apply)

Medical record abstract i

Ambulatory Surgery Records i

Itemized Billing Statement i

Consult Reports Only i

Discharge Summaries i

Emergency Department Only i

Full medical record i

Immunization List Only i

Laboratory Reports Only i

Operative Reports Only i

Pathology Report(s) i

Provider Notes Only i

Radiology Reports Only i

From Date i

To Date i

Disclosure of sensitive information

You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing. Include (Indicate by checking below): Please note that the information will not be released if not checked.

Mental Health Testing/Treatment (except psychotherapy notes) i

Alcohol/Drug Treatment/Testing i

HIV/AIDS Related Information i

Genetic Testing Information i

I authorize the disclosure of ALL sensitive information

I DO NOT authorize the disclosure of ANY sensitive information

Other Comments/Notes

Delivery Method

Released By

Please consider the environment. When possible, we will provide the information you requested electronically please check preference:

Receive electronic copy of records or Email i

Mail CD (If you choose this method there may be additional costs.) i

Mail Paper Records i

Fax i

Connect Patient Portal
Patients with an active electronic medical records account (patient portal) can request electronic delivery via secure web patient portal at no cost. Please confirm by checking the box above. i

The purpose(s) for which disclosure is authorized (check where applicable):

Patient’s request

Care at another facility/provider

Life Insurance

Legal

Disability

Worker's Comp

Today's Date

Consent Form Expiration Date i

Review & Submit

Cancel my request for records

Authorization for Release of Medical Information

For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information

Your Information

Supporting Documentation

Authorization to release my medical records

Information to Release

Disclosure of sensitive information

Delivery Method