Harlem United /URAM Records Release Form
If you would like to fill out this form in person, please contact us here  or 844-GO HARLEM ext.3267


CONSENT

I do hereby consent and Authorize Harlem United/URAM to release copies of my medical records.
Choose the correct record request type:
Choose the correct record request type:
Your Information
Your Information
Where would you like your medical records to be sent?
Where would you like your medical records to be sent?
Please select all the specific documentation that apply to your request
Please select all the specific documentation that apply to your request
                             
 
Place your initials below the options below to authorize the release of sensitive information pertaining to:
Mental Health
Alcohol/Drug Treatment
HIV/AIDS
Please select the purpose of your request:
Please select the purpose of your request:
 
Please select the Date Range of your request.
Please select the Date Range of your request.
Patient Signature  and Date:
Medical Records Fees

Patient Requests:

Most of our patients can quickly access their accurate medical records
via our patient portal. Ask our Health center staff how to access your
records today. There is no charge for portal access to your records.


Third-party requests:

• $0.75 cents per page up to 500 pages
• $0.40 cents per page for 500+ page