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.
Correspondence – HIS
600 Roe Avenue
Elmira NY 14905
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.
- Use of the Medical Records Release Form is not required but may speed processing.
- 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.)
- 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).
- If records are to be released to yourself, we will process your request within 10 days upon receipt.
- 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.
- 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.
- 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.
- 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.