NYU
Instructions for Requesting
a Co1v of vour Health Record
Please be advised that in order to obtain a copy of your clinical health record, you must complete the
form The form is available as a PDF file at
If your health records contain information relating to HIV or AIDS, the New York State Department of
Health requires a special authorization form -
The form is available as a PDF file at
If you wish to obtain a copy of your counseling record, you must complete the form
The form is available as a PDF file under
You may visit the Health Information Management Services office and complete the necessary forms
on-site or you may fax or mail your completed request form to our office. The fax number is (212)
443-1002.
726 Broadway, Suite 336
New York, NY 10003
Please allow 3-10 business days for processing of your request.
Health records will be sent to another healthcare provider free of charge as a professional courtesy.
However, records not going directly to another healthcare provider are copied at the rate of 75 cents per
page.
Students requesting that a copy of their health records be released directly to them will receive the first
20 pages free of charge, with each additional page copied at the rate of 75 cents per page.
Health records will be released upon payment of all fees.
HIMS will provide you with copies of radiology reports (written results of your x-rays).
However, if you require copies of your radiology films, you must contact Radiology Services directly at
(212) 443-1072.
When requesting health information, please be very specific to insure you receive the information you
require. Also, please be advised that HIMS will process fully completed Authorization for Release of
Information forms, as required by federal law (HIPAA).
If you have any questions regarding the release of your health records (clinical and/or counseling),
please contact the HIMS Correspondence Unit at (212) 443-1272 or health.hi[email protected].
726 Broadway, 3rd Floor• New York, NY 10003-9580 • (212) 443-1272 • Fax: (212) 443-1002 • www.nyu.edu/health • [email protected]
3/23/15
NYU
Authorization
for
Release
of
Health
Information
We
understand
that
information
about
you
and
your
health
is
personal,
and
we
are
committed
to
protecting
the
privacy
of
that
information.
Because
of
this
commitment,
we
must
obtain
your
written
authorization
before
we
may
use
or
disclose
your
health
information
for
the
purposes
described
below
unless
there
is
a
serious
or
imminent
threat
to
the
health
and
safety
of
you
or
others.
This
form
provides
that
authorization
and
helps
us
make
sure
that
you
are
properly
informed
of
how
this
information
will
be
used
or
disclosed.
Please
read
the
information
below
carefully
before
signing
this
form.
I,
or
my
authorized
representative,
request
that
health
information
regarding
my
care
and
treatment
at
New
York
University
Student
Health
Center
or
_________________________
be
released
by
NYU
Student
Health
Center
or
_________________________
to
the
party
named
below.
Please
be
advised
that
if
your
health
records
contain
information
relating
to
HIV
(Human
Immunodeficiency
Virus
that
causes
AIDS),
New
York
State
requires
a
separate
written
authorization
for
release
of
this
information.
Please
inform
Health
Information
Management
Staff
if
you
need
to
sign
the
NYS
authorization
form.
All
5
sections
must
be
fully
completed.
1.
Name
of
person
whose
information
will
be
released
(Please
Print)
:
__________________________________________
Date
of
Birth:
____
/
____
/
____
Student/Employee
I.D.
#:
____________________________________________
Address:
______________________________________
Telephone:
_
(
______
)
_____________(______
)
________
Daytime
Evening
2.
Name(s)
and
adress(es)
of
person(s)
who
will
be
receiving
this
information:
3.
Reason
for
disclosure
of
information:
°
Follow-up
Patient
Care
°
New
School
°
Insurance
Issues
°
Individual's
Request
°
Other
(please
specify):
_______________________________________________________________________
4.
Information
to
be
used
or
disclosed
(include
dates
where
appropriate)
:
Please
check
all
that
apply.
°
Allergy,
Immunology
&
Travel
Medicine
Services
°
Complete
Medical
Record
°
Immunization
Records
ONLY
°
Infectious
Diseases
(HIV/AIDS
requires
a
New
York
State
authorization
form)
°
Laboratory
Results
Specify
types:
__________________________________
°
Nutrition
°
Physical
Exam
(most
recent)
Date:
_________________________________________
°
Physical/Occupational
Therapy
Dates:
_________________________________________
°
Primary
Care
Services
Dates:
________________________________________
Continued
on
Reverse
Side
►
NYU
Student
Health
Center
|
Health
Information
Management
Services
726
Broadway,
3rd
Floor
•
New
York,
NY
10003-9580
•
(212)
443-1272
•
Fax:
(212)
443-1002
•
www.nyu.edu/health
•
3/23/15
I, or my authorized representative, request that health information
regarding my care and treatment at New York University Student Health
Center or
Student/Employee ID Number:
D
D
D D
D D
D D
D D
D D
D
