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Request Medical Records

If you would like to request medical records from NYU Langone Hospital—Long Island, please download and complete the Authorization for the Use & Disclosure of Protected Health Information (PHI) Form below:

Request English Version

Request Spanish Version

The form must be completed in its entirety. Once completed, the form must be either mailed or faxed to the following address*:

NYU Langone Hospital—Long Island
Health Information Management Department
259 First Street
Mineola, NY 11501
Fax: 516-663-8910

Once your request is received, the number of pages requested will be calculated and an invoice will be sent. The charge for copies of medical records is $0.75 per page. Once payment is received, records will be sent within 10 business days. If the request is being sent directly to a provider for follow-up care, it will be processed accordingly at no charge.

If you have any questions, please contact the Health Information Management Department at 516-663-2512.

*Requests can not be sent electronically – an original signature must be present.