INSTRUCTIONS: Print print the applicable form, and complete all information in blue or black ink. Submit the form according to directions written on the form.
Release of health records; notice of privacy practices
- Authorization for Release of Health Records (pdf)
- Notice of Privacy Practices (pdf)
- Acknowledgment of Privacy Notice -- Under Age 18 (pdf)
Please see patient rights forms related to your Protected Health Information (PHI) below.
- Health History for Faculty, Staff, or Student Dependent (pdf)
- Health History for Visitor or Short-term Employee Health History Form (pdf)
- AUHSP medical evaluation form (pdf)
- Travel Clinic History (pdf)
If you filled this form out via myCornellHealth, you do NOT need to fill out a paper copy.
Department charge authorization
- Department Charge Authorization (pdf)
If your visit is to be paid for by a Cornell account, you must complete this form before your visit.
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)