Medical Record Request Form printable pdf download

Medical Record Request Form

Sarah Lawrence College

Health Services

One Mead Way, Bronxville, NY 10708

(914)395-2350

Medical Record Request Form

Name (used at SLC): ______________________________________________

Date of Birth: _____________________________________________________

Student ID #: _____________________________________________________

Month/Year last attended SLC: _____________________________________

Telephone: ______________________________

email: __________________

Please indicate the records you are requesting:

⁭

Medical Record

⁭

Mental Health Record

⁭

Immunization Record

⁭

Laboratory/ Radiology Reports

⁭

HIV/AIDS Information

⁭

Other ___________________________________________________

Please indicate below, where you are requesting the records be sent.

Name: _____________________________________________________

Institution: _________________________________________________

Address: ___________________________________________________

___________________________________________________

Telephone: ___________________ Fax: _________________________

Patient Release of Information:

I, ____________________________authorize Sarah Lawrence College Health Services

to release the records indicated above to the named provider/institution.

________________________________________

_________________

Signature

Date

Fax, mail or hand deliver signed form to:

Sarah Lawrence College Health Services

One Mead Way

Bronxville, N.Y. 10708

914-395-2640 (fax)

Please allow up to 2 weeks for completion of request

Medical Record Request Form