Medical Record Request Form Page 2

Sarah Lawrence College

Health Services

One Mead Way, Bronxville, NY 10708

(914)395-2350

REQUESTING YOUR MEDICAL RECORD

When requesting a copy of your medical record from Sarah Lawrence College Health

Services, please submit the signed “Medical Record Request Form” by fax, mail or

hand delivery.

There is no charge for records requested for continuation of care purposes that are

sent directly to your provider.

There is a $10 fee for a request of your medical or mental health record and a $5 fee

for a request of your immunization record that is not sent directly to your provider.

Please submit appropriate fee, by check, with the “Medical Record Request Form”.

All records will be mailed/faxed within two weeks of request.

Any questions can be directed to Sarah Lawrence College Health Services

914- 395-2350.

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