Medical records request forms – New York
Medical records request forms – New Yorkformer ProHEALTH
Patients can view their Protected Health Information (PHI) through the MyChart patient portal. If the information isn’t available in MyChart, patients can submit a request for their records online using the Patient Medical Records Request Tool.
Patient online records request
Provider online records request
Printable Release of Information (ROI) forms are also available in English and Spanish for patients who do not wish to make use of the online options.
Forms submitted with incomplete or unreadable information, insufficient legal authority, or signed by the incorrect individual may result in processing delays. If you are using this form for another individual (patient), you can complete the Release of Information form.
Release of health information (English)If you are not the patient, but an authorized representative by law, you will need to provide supporting documentation showing this, when submitting the completed form.
Optum may impose a reasonable, cost-based fee for a copy of your PHI, as permitted by the HIPAA Privacy Rule and state law.
Return the completed form using one of the options listed below:
- Fax: 1-516-812-4305
- Mail: Optum Medical Care, New York (FKA ProHEALTH)
Health Information Management Department
3 Delaware Drive, Suite 206
Lake Success, NY 11042