If you would like to submit a medical record request, please click on the following link(s) below.
Please note that different forms are used if you are the patient or if you are a patient representative making the request.
All requests will be processed within ten (10) business days of receipt of the requests.
Online Patient Medical Request Form
Click here to submit a request as a patient. (English)
Click here to submit a request as a patient. (Spanish)
Online Patient Representative Medical Request Form
Click here to submit a request on behalf of the patient. (English)
Click here to submit a request on behalf of the patient. (Spanish)
Online Patient Attorney Medical Request Form
Click here to submit a request on behalf of the patient.
To download the Patient/Representative Medical Request Form (English) Click here.
To download the Patient/Representative Medical Request Form (Spanish) Click here.
Please use the following contact information if you have questions regarding medical release forms:
Email: Sbcm-verisma@stonybrookmedicine.edu
Fax: (631) 994-3301
Customer Service Phone: (866) 786-1996