Release of Information

Please note that New York Public Health laws restrict the release of medical information without the consent of the patient. This law applies to all patients. Information can only be released to parents or guardians of students less than 18 years of age without the patient's consent. However for any patient 18 years of age or older, a signed written consent is required for the release of any information to parents, guardians or anyone else.

If you wish to have medical information released you can print, complete and sign the form below. The form MUST be signed by the patient (unless patient is under 18 years of age, then the parent or guardian must sign). 

Please also note that the release must have a defined end date and this date cannot be any time in the future. We often get requests from patients and parents that the patient make a "blanket request that all information be released for the future just in case something happens." This is contrary to public health law and therefore not possible.

Release of Information Form (PDF)