How do I complete the form?
A paper form can be downloaded from the Stony Brook Eastern Long Island Hospital site.
Patient Name
Please provide the patient’s full name.
Patient’s Date of Birth
Please provide the month, day and 4-digit year (mm/dd/yyyy).
Patient’s Address
Please provide the number, street, city, state and zip code.
Telephone Number
Please provide the full telephone number with the area code.
Email address
Please provide your email address.
Medical Record Number
Please provide your medical record number, if known.
Address of where copies should be sent
If the patient is requesting records for themselves and the full address is indicated above, the patient can check the box “same as above”
If the patient is requesting records be sent to a physician, an insurance company, or an Attorney’s office the full address is required.
Dates of service being requested
Specify the dates the patient was seen and/or the dates of service that you are requesting (please do not use range of years.)
Indicate the information you would like to be released
History and Physical, Operative or Procedure Reports, Labs, Radiology, Pathology, discharge summary and other reports.
Check off or Initial where sensitive information may be considered
If the record contains information related to Alcohol/Drug treatment, Mental Health treatment, HIV/AIDS, and/or Genetic Testing information you must check off or initial where specified. If not checked or initialed and the record contains any of the above listed information, the records may be delayed.
Indicate preferred method of delivery
CD/DVD, paper or electronic.
Indicate the purpose of requesting the records
Please indicate the reason the records are being requested.
Sign and date the form
Please provide your signature.
