Forms

Form submission instructions: 

1. Download or print the applicable form below, and then complete all information. (Please use blue or black ink if completing 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   

Release of health records; notice of privacy practices

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

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)

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)

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.