Forms

Optional healthcare forms 

Commonly requested by parents of new students:

• Permission to Share Personal Health Information (pdf)
  Students age 18+ can submit this form to give Cornell Health permission to verbally discuss specific Personal Health Information (PHI) with a family member(s) and/or other trusted individual(s). (Can be submitted or revoked at any time; must be renewed annually.)
• Health Care Proxy Form
  The New York Health Care Proxy Form enables individuals 18+ to designate someone to make health care decisions for them if you become unable to make health care decisions for yourself. Some students and families choose to have a health care proxy form on file with Cornell Health (the chosen proxy should also keep a copy).

Release of health records; notice of privacy practices

• Permission to Share Personal Health Information (pdf)
• Authorization for Release of Health Records (pdf)
• Notice of Privacy Practices (pdf)

   > How to submit your form(s)

Protected Health Information (PHI) patient rights forms

The Health Insurance Portability and Accountability Act (“HIPAA”) gives you the right to make the following requests regarding your Protected Health Information (PHI):

• Request to Inspect your PHI (pdf)
• Request to Amend your PHI (pdf)
• Request for Confidential Communications of your PHI (pdf)
• Request for an Accounting of Disclosures of your PHI (pdf)
• Request to Restrict Certain Uses and Disclosures of your PHI (pdf)
• Request to Restrict Disclosures of your PHI to an Insurer (pdf)

   > How to submit your form(s)

Health forms

• AUHSP Medical Evaluation Form (pdf)
• Travel Services History (pdf)
  If you filled this form out via myCornellHealth, you do NOT need to fill out a paper copy.
• Nursing Order Form for Medication Injections at Cornell Health (pdf)

   > How to submit your form(s)

Department charge authorization

• Department Charge Authorization (CU NetID required)
  If your visit is to be paid for by a Cornell account, you must complete this form before your visit.

How to submit your form(s): 

1. Download or print the applicable form above, and then complete all information. (Please use blue or black ink if completing and/or signing a printed form.)
2. Submit the form to Cornell Health in one of the following ways (unless otherwise specified on the form):
   • Upload the form through myCornellHealth (Cornell NetID required): go to Messages > New Message > Send message or attachment to Health Records
   • Fax it to 607-255-0269
   • Drop it off or mail it to:
     Cornell Health
     ATTN: Health Records Department
     110 Ho Plaza
     Ithaca , NY 14853-3101   

Please note that forms cannot be accepted by email.