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