Are you a patient looking for copies of your medical records?
The best place to get information about your own personal health records is through your primary care or specialist physician. Please contact your doctor for copies of your medical records or test results.
Due to the sensitivity of confidential and protected health information, we are unable to respond to inquiries from individual patients submitted directly to our website. If you need assistance, please contact us toll-free at 1-877-344-8999, and select option 1. A Customer Service Specialist is available to answer all inquiries and any other requests.
This medical record information release (HIPAA) form allows patients to give authorization to a third party to access their health records and allows your healthcare provider to share your health information.
Important: Some healthcare systems have customized forms that are not listed on this page. If you have questions about a form, call your doctor’s office.
English language release form
Spanish language release form
Hospital system specific authorization forms
You can find patient authorization forms for specific facilities below.
To expedite the process, please make sure you:
- PRINT the full name of the person seeking care
- SIGN and DATE the form
- FAX or MAIL the form to: 866-920-5565 or eHealth Technologies, 250 Thruway Park Drive, West Henrietta, NY 14586
- eHealth Technologies Patient Authorization Form
- eHealth Technologies Clinical Trials/Right to Access Patient Authorization Form
- Record Retrieval User Change Form (PDF)
- Columbia University Department of Anatomic Pathology: Authorization to Release Medical Information
- Columbia University Medical Center: Authorization to Release Medical Information
- Hinge Health: Authorization to Release Medical Information
- Mayo Clinic: Authorization to Release Protected Health Information
- Mindstrong Health: Gabe Aranovich, MD
- Mount Sinai Medical Center: Patient Authorization for Release of Medical Information
- National Institute of Health: Authorization for the Release of Medical Information
- New York City Health and Hospitals Corporation (NYCHHC): HIPAA Authorization to Disclose Health Information
- NewYork-Presbyterian Hospital: Authorization Form to Disclose Protected Health Information/Medical Records (English)
- NewYork-Presbyterian Hospital: Authorization for the Release of Medical Information and Acknowledgement of Responsibility (English)
- NYU Langone Medical Center: Authorization for Release of Protected Health Information (PHI)
- Oschner Medical Center: Authorization for Release of Confidential Information (English) and Authorization for Release of Confidential Information (Spanish)
- Thomas Jefferson University: Consent to Release Medical Information
This clinical trial release form allows patients to give authorization to a third party to access their health records and allows your healthcare provider to share your health information.
Clinical trials / right to access patient authorization form
HIPAA Form H004-2023
Patient authorization for release of medical records for patient right to access.