Suny downstate medical center medical records 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name and Address in the designated fields. Ensure that all information is accurate for proper identification.
3. Fill in your Medical Record Number (MR#) and Date of Birth (DOB) to help streamline the processing of your request.
4. Provide your telephone numbers for both day and evening contacts, ensuring you can be reached easily regarding the research study.
5. Specify the name of the physician or research investigator along with their department at SUNY Downstate Medical Center who will receive your information.
6. Clearly state the name of the research study or protocol you are authorizing disclosure for, as well as any specific information that will be disclosed.
7. If applicable, indicate whether you authorize the release of sensitive information such as mental health or HIV-related data by checking the appropriate box and specifying details if necessary.
8. Set an expiration date for this authorization, which will end at the conclusion of the subject recruitment phase unless otherwise noted.
9. Finally, sign and date the form to complete your authorization. Remember to keep a copy for your records.

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