PATIENT REQUEST FOR DISCLOSURE
I hereby authorize __________________________ to disclose the following information from my health record
Patient
name: __________________________________________ Date of birth: _______________________
Address
: ____________________________________________ 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) in
fection
Behavioral health services/psychiatric care.
Treatment for alcohol and/or drug a
buse.
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
