CUHA Medical Records Request Form

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.Format: (000) 000-0000.

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?

Recipient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Recipient Phone:

(Area Code) Phone NumberFormat: (000) 000-0000.

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:

Other

The information will be used/disclosed for the following purposes:

Other

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

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.

Form Status

Assigned to:

Notes:

Created 2/24

Medical Record Request

Internal Use only: