Medical Records Release

In order to facilitate the obtaining of records from World Trade Center Health Program Clinics that are needed by Responders and Survivors, for their September 11th Victim Compensation Fund claims, 911Health Watch has created this page with information and forms to make it easier for law firms to find the appropriate medical release forms and where they should go to request records for each clinic.

We are also posting a suggested cover request that can be used by law firms to send in along with World Trade Center Health Program clinics’ own forms to help standardize the requests and thereby speed the procurement of the necessary records that the September 11th Victim Compensation Fund needs.

We would suggest that law firms seeking records complete the

  1. Suggested cover form and then
  2. The clinic’s own medical records release form, which are each below and send them into the clinics, whose contact information is also below.


1. Suggested Cover Form

          Here is a suggested cover form for law firms to submit with a medical records request for a World Trade Center Health Program Clinic

          Suggested Medical Records Request Cover Form

2. Program Clinic Medical Records Release Forms

Here are the forms that are needed for each of the clinics:

          For Responders – Clinics:

                          The FDNY Responder Health Program

FDNY Clinic Medical Records Request Form

Completed forms must be mailed or faxed to:
FDNY World Trade Center Medical Monitoring & Treatment Programs
Attention Medical Records
9 MetroTech Center
Brooklyn, N.Y. 11201
Phone: 718-999-1858
Website: FDNY Website

Icahn School of Medicine at Mount Sinai Selikoff Centers for Occupational Health Mount Sinai Medical Center

Mt. Sinai Clinic Medical Records Request Form

Completed forms must be sent by mail to:

Mount Sinai Hospital
Medical Records
One Gustave L. Levy Place – Box 1111
New York, NY 10029
Telephone: (888)702-0630 or (212) 241-1554
Website

New York University School of Medicine Bellevue/NYU Department of Occupational & Environmental Medicine

NYU Bellevue Responder Clinic Medical Records Request Form

Completed forms must be mailed or faxed to:

Health Information Management (HIM),
NYU Langone Medical Center
560 First Avenue, New York, NY 10016
Telephone: (212) 562-4572
Web site

Queens WTC Clinical Center of Excellence at North Shore-LIJ

Queens LIJ Clinic Medical Records Request Form

Completed forms must be mailed to:
Queens WTC Clinical Center of Excellence at North Shore-LIJ
Attention Medical Records
97-77 Queens Boulevard, 9th Floor
Tel. 718-267-2420/ Fax. 718-267-2445
Website

Rutgers University Robert Wood Johnson Medical School Environmental & Occupational Health Sciences Institute

Robert Wood Johnson Clinic Medical Records Request Form

Completed forms must be mailed or faxed to:

Robert Wood Johnson Medical School
Environmental & Occupational Health Sciences Institute
Attention: Medical Records
170 Frelinghuysen Road
Piscataway, NJ 08854
Telephone: (848) 445-0123 press #3 for the WTC-HP or #0 for operator assistance
Website

State University of New York, Stony Brook

Stony Brook Clinic Medical Records Request Form

Completed forms must be sent by Mail/Fax to:
World Trade Center Health Program
Attn: Medical Records
1345 Motor Parkway, 1st Floor
Islandia, NY 11749
Telephone: (631) 855-1200
Website

          For Survivors – Clinics:

                                                                               New York City Health & Hospitals Corporation World Trade Center Environmental Health Center

HHC Survivor Clinics Medical Records Request Form

There is a single HIPAA Authorization to Disclose Health Information form for all New York City Health & Hospitals Corporation facilities. The online link to obtain the form in various languages is: http://www.nyc.gov/html/hhc/html/home/hhc-authorization.shtml

The specific facility is identified when the requestor fills out the form by entering that facility name in the box labeled “Name of Health Provider to Release Information”. The requestor will enter either Bellevue Hospital Center, Elmhurst Hospital Center, or Gouverneur Healthcare Services, depending on the patient’s site of WTC-related care.

Completed forms can be mailed or faxed by a requesting provider or attorney, while patients are requested to mail or hand deliver the form (not fax) to the appropriate facility’s Medical Correspondence Department:

Bellevue Hospital Center
462 First Avenue
New York, NY 10016
Attn.: Medical Correspondence
Phone: 212-562-8801
Fax: 212-562-8585

Elmhurst Hospital Center
79-01 Broadway
Elmhurst, NY 11373
Attn.: Medical Correspondence
Phone: 718-334-3140
Fax: 718-334-2659

Gouverneur Health
227 Madison Street
New York, NY 10002
Attn.: Medical Correspondence
Phone: 212-238-7116
Fax: 212-238-7009

          For Responders and Survivors – National Program:

                          World Trade Center Health Program Nationwide Provider Network

1. LHI Authorization for Release of Information
2. LHI Release Form Instructions

Completed forms must be mailed or faxed to:
World Trade Center Health Program Nationwide Provider Network
Attn: Records Management Department

328 Front Street South
La Crosse, WI 54601
Phone 866-284-8788
Fax: 608-793-2964
Website