INSTRUCTIONS: Download or print the applicable form, and then complete all information. If you are not completing electronically, please use blue or black ink. Submit the form according to directions indicated on the form.
Release of health records; notice of privacy practices
- Authorization for Release of Health Records (pdf)
- Health Record Access Designee Authorization (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)
- 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.
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.