New York Medical Records Release Form 1
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I, __________________________________, authorize Weill Cornell Medical Associates to release a
(Person requesting medical records)

copy of my medical record to:
Please Provide Records Via
( ) Regular Mail
( ) CD in PDF format
( ) FAX
My physician at Weill Cornell Medical Associates is/was:
Reason for Request: ( ) moving ( ) changed insurance ( ) transferring care for other reason
( ) release info to specialist ( ) other
I specifically authorize the release of the following:
_____ Pertinent Record (includes the previous 3 years of office notes, lab work, and ALL other
pertinent tests)
_____ Entire Chart (please be aware the charge for this may be several hundred dollars, depending on
the size of the chart. The entire record will remain on file indefinitely in our electronic record if
there is ever a need to access it, and most physicians will not require the entire chart)
Patient Comments/Notes

I expressly and voluntarily authorize disclosure of the above