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:
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
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.