Medical Records Request Form

To request release of your medical records or a copy of your medical records, complete the release form and send it to Arnot Ogden Medical Center's Health Information Services.

Medical Records Release Form (pdf)

Medical Records Release Form for HIV Records (pdf)

Correspondence – HIS
Arnot Health
600 Roe Avenue
Elmira  NY  14905

Fax: 607-737-4403

Questions?
Contact the Correspondence Coordinator at the Health Information Services Department:  607-737-4302, option 6, Monday - Friday, from 8:00 a.m. - 4:00 p.m..  To check the status of a request, choose option 3 or ask to be transferred to MRO.

Release Requirements

1. Use of the Medical Records Release Form is not required but may speed processing.  For the release of HIV information, use Medical Records Release Form for HIV Records.
2. Any patient who is 18 years or older must sign the release.  For patients under 18 years old, the patient or guardian must sign the release.  (Some exceptions may apply.)
3. If releasing records to yourself or to an attorney, release must be notarized. A fee of 75 cents per page will apply.  (Pursuant to SECTION 18 of the New York State Public Health Law). 
4. If records are to be released to yourself, we will process your request within 10 days upon receipt.
5. If records are sent directly to a physician, facility, nursing home or insurance company for payment of the visit, there is no charge and release does not need to be notarized.
6. If patient is deceased, the release must be notarized and signed by the patient’s personal representative as described by NYS law. Legal proof of personal representative status is required.
7. Provide as much information as possible: patient name, date of birth, name of doctor, approximate date of visit, treatment rendered, fax and address for receipt of records.
8. Initial expiration date, revocation section, and drug, alcohol, and psychiatric exclusion.  If patient does NOT wish sensitive information to be released, check the exclusion box.