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Request Medical Records

Harlem United and Upper Room AIDS Ministry (URAM) patients have the right to access their health information according to federal and state law, including HIPAA regulations designed to protect patient privacy.

Patients and authorized patient representatives can request, in writing at any time, a copy of their health records, to review or to receive copies of their records to forward to other providers and third parties.

Requests will be processed within 7-10 business days.

1. The patient may submit this form to obtain their medical records.

2. We generally accept the following HIPAA Forms:

Print out the New York State DOH-­5032 or Click here                                          
Print out the OCA Official Form No. 960 or Click here    
Other authorizations that comply with NYSDOH regulations for patient privacy may also be accepted

3. Completed requests are forwarded to the Compliance/Medical Records Department at:

Fax: 212-531-1085
Tel: 212-531-1300 x 3267

4. Patients may request specific portions of their medical record, such as a list of medications and/or results of last lab work, in person at

Harlem United – Willis Green
123-125 West 124th Street
2nd Floor – Medical Records
New York, NY 10027

Special Circumstances:

  • If the patient is incapacitated, or unable to sign for themselves, the patient representative must enter relationship to the patient.
  • If the patient is deceased, the established next of kin, court-appointed administrator or executer of the state can request the medical records. A copy of the death certificate is required to verify death.


Shaneequa Parker, Director of Compliance at
Joy Gant, Medical Records Coordinator at