Medical Record Request Forms

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.

 

Online Patient Representative Medical Request Form

Click here to submit a request on behalf of the patient.

 

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

 

Last Updated
02/01/2023