I hereby authorize __________________________ to disclose the following information from my health record
ent name: __________________________________________ Date of birth: _______________________
ss: ____________________________________________ Telephone: _________________________
____________________________________________ Medical Record Number: _____________
Dates of Treatment being requested: _______________________________________________________________
Requested Information:
Abstract (subset of records) Emergency Record Autopsy Report
Discharge Summary Laboratory Testing Pathology Report
Operative Report Consults Endoscopy/Colonoscopy
Radiology (X-Ray, MRI,etc.) Cardiac Testing Complete Record
Cardiac CD
Other (please specify) _____________________________________________________________________
I understand that this may include sensitive information relating to:
Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV)
Behavioral health services/psychiatric care.
Treatment for alcohol and/or drug a
This information is to be released to: ________________________________________
Please send by the following method:
Printed copy @ 75 cents per page CD @ $6.50 Electronic download @ $6.50
e-Mail to ____________________________________ @ $6.50
(print very clearly)
Please note: e-mail is not a secure method of transmission of your health information. Stony Brook Medicine is not
responsible for the privacy of information e-mailed at your request.
Signed: ______________________________________________________________ Date: _____________
(Patient) or (Parent/Legal Guardian)
____________________________________________________ Date: _____________
Health Care Agent Only if the patient lacks capacity to sign for his/her self
MR2N585 (7/17)