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:
Medical Record
Case/Care Management Record
Your Information
Your Information
Client/Patient Name
Medical Records Number
Date of Birth
Social Security (Last 4 digits)
Phone Number
Address/Street Number
City
State
Zip
Where would you like your medical records to be sent?
Where would you like your medical records to be sent?
Name of Person/Facility
Address
City
State
Zip Code
Phone
Fax
Email
Please select all the specific documentation that apply to your request
Please select all the specific documentation that apply to your request
Primary Care Notes
Behavioral Health Clinic Notes
Dental Clinic Notes
Specialty Notes (Podiatry, Cardiology, GYN)
Progress Notes (Case/Care Management Notes)
Discharge Summary
Radiology Reports
Lab Reports
Pathology Reports
Urgent Care
Nurses Notes
Operative Reports
EKG/EEG/EMG
Emergency Room Records
Provider Consult Reports
Other
Place your initials below the options below to authorize the release of sensitive information pertaining to:
Mental Health
Mental Health
Alcohol/Drug Treatment
Alcohol/Drug Treatment
HIV/AIDS
HIV/AIDS
Please select the purpose of your request:
Please select the purpose of your request:
Continued Patient Care
Attorney/Legal
Insurance
Worker's Compensation
Personal (no HIPAA Needed)
Social Security
Other
Other
Please select the Date Range of your request.
Please select the Date Range of your request.
Start Date
End Date
Patient Signature and Date:
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