All forms are in PDF format unless otherwise noted.
Application for Medical Emergency Funding
Available for Full-time Graduate and Professional students only.
Health Information Management Services
726 Broadway, 3rd Floor
New York, NY 10003-9580
Phone: (212) 443-1272
Fax: (212) 443-1002
Your health records are maintained in compliance with both federal and New York State laws.
If you are a new patient and have an on-going medical condition (e.g. diabetes, epilepsy, heart disease, allergies, etc.), it is important that we have a summary of your medical history to provide you with the best possible care.
You may send the information to Health Information Management Services (HIMS) at the address above for inclusion in your confidential health record.*
*Please ensure that this information is identified with your name, date of birth, and student I.D. number.
For students under 18 years of age, a parental or legal guardian authorization for medical treatment form must be on file in our office in order for you to receive prompt care and treatment, should the need arise. Please complete and return the Authorization for Treatment of a Minor (PDF) form to the address above.
To Request a Copy of Your Health Record:
If you wish to obtain a copy of your health record, you must submit a written request to the HIMS Office. You may use the request form Authorization for Release of Health Information (PDF) for a printable copy. All information must be completed in order for your request to be processed.
PLEASE NOTE: If you are requesting copies of x-ray examinations, HIMS can provide you with copies of written results of your x-rays. if you need copies of your radiology films, you must contact Radiology Services directly at (212) 443-1072.
If your health records contain information relating to HIV or AIDS, the New York State Department of Health requires a special authorization form - Authorization for Release of Confidential HIV Related Information (PDF). You may visit our department and complete the necessary forms on-site or you may fax or mail your completed request form to our department.
Health records will be sent to another healthcare provider free of charge as a professional courtesy. However, records not going directly to another healthcare provider are copied at the rate of 75 cents per page. Health records will be released upon payment of all fees. If you have any questions regarding the release of your health records, please contact the HIMS Correspondence Unit at (212) 443-1272.