How to Fill Out and Submit the NUMC Medical Records Request Form

To request medical records from Nassau University Medical Center, send a signed HIPAA authorization form to the hospital’s Health Information Management (HIM) department at 2201 Hempstead Turnpike, East Meadow, NY 11554, or deliver it in person Monday through Friday, 8 a.m. to 5 p.m. The HIM Correspondence Unit answers at (516) 572-6446 or (516) 572-6445.¹ New York caps paper copy fees at $0.75 per page, and there is no charge when the records support an application for a government benefit.

Which Authorization Form Works

NUMC accepts the standard New York authorization forms. Two are in common use:

OCA Form No. 960, “Authorization for Release of Health Information Pursuant to HIPAA,” created by the New York State Office of Court Administration.²
DOH-5032, published by the New York State Department of Health, with built-in checkboxes for substance abuse, mental health, and HIV/AIDS records.³

NUMC may also hand you its own version at the HIM desk. Any of these is valid as long as it meets HIPAA’s core requirements: it identifies the patient, describes the information to be released, names the recipient, states the purpose, sets an expiration date or event, and is signed by the patient.⁴

Filling Out the Form Without Getting It Bounced Back

A blank field is the fastest way to have your request returned. Work through the form carefully.

Patient Identification

Put down the patient’s full legal name, date of birth, and address. DOH-5032 also asks for a patient identification number, which is the medical record number on your discharge paperwork or billing statements; call HIM if you can’t find it.³ A nickname or maiden name that doesn’t match the file will delay things.

Where the Records Go

The form has two address blocks: the provider releasing the records (NUMC’s HIM department) and the recipient. If a new doctor is receiving the records, put down the practice’s full name and mailing address. If you want the records yourself, list your own address. Incomplete recipient information is one of the most common reasons forms get returned.

What Records and Which Dates

Write in the dates of service and specify what you want: lab results, radiology, discharge summaries, operative notes, or the complete chart. Being specific saves back-and-forth. If you’re unsure of exact dates, give your best estimate and note the reason for the visit.

Sensitive Categories Need Separate Initials

Certain records are protected more heavily under state and federal law and will not be released unless you specifically authorize them. On the DOH-5032, initial next to each category you want included:³

Substance abuse treatment records
Mental health clinical records
HIV/AIDS-related information

Skip the initials and those records will be withheld even if you asked for “all records” elsewhere on the form.

Purpose, Expiration, Signature

State the purpose. Common entries are “continuity of care,” “personal use,” “insurance,” or “legal matter.” Set an expiration date or event, such as “90 days from signature” or “upon resolution of my insurance claim.” HIPAA requires a clear endpoint.⁴ Sign and date. If you are signing for someone else, the form also needs your name and your legal authority.

How to Submit It

You have three ways to get the signed form to HIM:

By mail to Health Information Management, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554. Use certified mail or a tracked service for proof of delivery.
In person, Monday through Friday from 8 a.m. to 5 p.m., at the HIM Correspondence Unit. Staff will log it while you’re there.¹
By fax, after calling (516) 572-6446 to confirm the current fax number.

HIM logs the request, verifies your signature against records on file, and contacts you if anything is incomplete or doesn’t match. Getting the identifying details right the first time saves weeks.

What It Costs and When It’s Free

New York Public Health Law § 18 caps paper copy charges at $0.75 per page, and the fee cannot exceed the facility’s actual cost of copying. NUMC calculates the total from the page count, sends an invoice, and releases records once you pay.⁵

Two exceptions matter. There is no fee at all when the records are for an application, claim, or appeal for a government benefit or program, including Social Security Disability, Medicaid, and veterans’ benefits. Write that purpose plainly on the form. And under § 18, NUMC cannot deny you access solely because you can’t pay. If cost is a barrier, raise it with HIM.⁵

How Long It Takes

New York Public Health Law § 18 requires a provider to give you the chance to inspect your records within ten days of receiving a written request. For copies, the statute says “within a reasonable time,” which at a hospital the size of NUMC generally means two to four weeks depending on volume.⁵

Very large requests or records stored in older archival formats sit at the longer end. HIM should tell you if a delay is expected. If several weeks go by with nothing, call (516) 572-6446. Requests do sometimes get lost in a busy department.

Requesting Records for Someone Else

HIPAA requires covered entities to treat a “personal representative” the same as the patient for record access.⁶ Who counts depends on the situation:

An adult with decision-making capacity signs for themselves, unless they’ve granted a health care power of attorney to someone else.
For an incapacitated adult, a court-appointed guardian or the holder of a health care proxy signs. Bring the court order or proxy document.
For a minor, a parent or legal guardian signs. New York law limits parental access to records for treatment the parent consented to or for emergency treatment following accidental injury or sudden illness.⁵
For a deceased patient, the executor or administrator of the estate can request records. If there is no will, distributees of the estate under New York’s Estates, Powers and Trusts Law also qualify. Bring a death certificate along with letters testamentary or letters of administration. A power of attorney does not survive death.⁷

Attach a copy of whatever legal document establishes your authority. HIM verifies it before processing, and missing paperwork is the most common reason representative requests stall.

Faster Access to Recent Records

For recent visit summaries, lab results, and basic health data, NUMC uses the FollowMyHealth patient portal at numc.followmyhealth.com, with a mobile app for iOS and Android.⁸⁹ The portal is good for records already loaded into the electronic system. For older records, department-specific records, or a complete certified copy of your chart, you’ll still need to submit the paper authorization to HIM.

If NUMC Denies or Ignores Your Request

You can file a complaint with the federal Office for Civil Rights at HHS. Complaints must be filed in writing within 180 days of when you became aware of the problem. Submit through the OCR Complaint Portal at ocrportal.hhs.gov, by email to OCRComplaint@hhs.gov, or by mail to Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F HHH Building, Washington, D.C. 20201.¹⁰

Identify NUMC by name and address, describe what happened and when, explain how your access rights were violated, and include your contact information and signature. HIPAA also prohibits retaliation for filing a complaint; if your care changes after you complain, tell OCR right away.¹⁰

1
NUMC. Phone Directory
2
NY Health Access. HIPAA Forms and Health Information Access and Privacy – Overview
3
New York State Department of Health. DOH-5032 Authorization Form
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eCFR. 45 CFR 164.508 – Uses and Disclosures for Which an Authorization Is Required
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New York State Senate. New York Public Health Code 18 – Access to Patient Information
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U.S. Department of Health and Human Services. Guidance – Personal Representatives
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New York State Department of Health. Department of Health Memorandum – Access to Patient Information
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FollowMyHealth. FollowMyHealth Sign In
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NUMC. Nassau Health Care Corporation Adds FollowMyHealth Online Patient Portal for Easy Access to Medical Records
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U.S. Department of Health and Human Services. How to File a Health Information Privacy or Security Complaint