CUHA Medical Records Request Form

Medical Record Request
Owner Name:*
Patient Name:*
Species:
Patient ID #:
Owner Address:*

Address

Street Address Line 2

CityState

ZIP
Owner Email:*
example@example.com
Owner Phone Number:*
Please enter a valid phone number.
I authorize Cornell University Hospital for Animals to release the above named patient medical records to:
Send Record To:*
Example: Vet Clinic or Insurance
Is the Address, Phone and Email the same as above?

YESNO
Recipient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Phone:*
(Area Code) Phone Number
Recipient Fax:
Recipient Email Address:
example@example.com
Dates of service From/To:
If no date supplied - most recent visit will be sent.
Description of information that may be disclosed:*

Laboratory ResultsImaging (Radiographs, US, CT, MRI, NM)Entire RecordOther
The information will be used/disclosed for the following purposes:*

Continuity/Transfer of careLegalInsurance/Payment of billsOther
I understand that by authorizing Cornell University Hospital for Animals, to use/disclose the information, that they may receive compensation for reasonable expenses incurred for making photo copies of medical records. I understand that I may revoke this authorization in writing at any time by contacting the medical record department, except to the extent that action has been taken in reliance on this authorization. This authorization expires(insert applicable date or event), on or within (6) months or the date of the authorization, whichever is greater.
Expire Date

MonthDayYear
Owner Signature*

Clear
Your request is important to us. Please allow 3-5 business days to complete your request. Please contact us at 607-253-3044 if you have any questions.
Note to Medical Record Team:
Additional information you'd like to provide to Medical Records regarding this request.
Internal Use only:
Form Status

NewIn progressPending DVM ReviewPending leadership approvalRecords SentNo client or pet on file
Assigned to:

Kortney HMichelle HDaniela M
Notes:
Created 2/24
Should be Empty:

Medical Record Request

Internal Use only: