Authorization for the Release of Health Information (Medical Services and CPS)

Routine requests for medical records are generally processed within 10 business days.

IMPORTANT: E-SIGNATURE REQUIRED

This form requires an e-signature to be valid. Please open the below PDF in Adobe Acrobat or another app that allows you to enter information on PDFs (there are many free versions online) to e-sign the document.

Ways to Submit Authorization Request

  • Email┬ácompleted form to [email protected]

  • Fax completed form to 212-851-9357

  • Mail:
    ATTN: Columbia Health Medical Records
    Wallach Hall, Suite 125, Mail Code 4202
    1116 Amsterdam Avenue
    New York, NY 10027