AUTHORIZATION TO RELEASE/OBTAIN MEDICAL RECORDS

There are two ways to RELEASE/OBTAIN your immunization records from SUNY Orange.

1. You may view and print your records from your student Banner account:

A. Log in to MySUNYOrange. In the Technical Services Tab, in Systems and Services for Students, select letter "I" then choose "Immunizations."

OR

B. Log in to MySUNYOrange. In the Technical Services Tab, in Systems and Services for Students, select letter "S" then choose "Student Profile," then click on the immunizations link in the left navigation.

2. You may complete this form to RELEASE your medical records from SUNY Orange or to OBTAIN your medical records from another institution, employer, etc. Please include a copy of your identification (i.e. student ID, driver's license) with request.

Status

Status Not Completed Completed By/Date Completed By/Date
Current Name Current Name * First Middle Last
Former or Maiden Name Former or Maiden Name First Middle Last
Do you know your student ID number (A number)? *

Do you know your student ID number (A number)? Yes No
Student ID Number (A number) *

The student ID is a 9-digit number starting with A00: i.e. A001234567. Be sure to add the 0's.
Date of Birth Date of Birth * / MM / DD YYYY
Email *
Phone Phone * - ### - ### ####
Health Information to Disclose

Health Information to Disclose Immunization Records Treatment Summary Health Professions Physical Clinical Clearance Form PPD History Flu Vaccine All Information Other Other
Method of Disclosure
Do you want to RELEASE or OBTAIN your medical records?

Do you want to RELEASE or OBTAIN your medical records? I want the SUNY Orange Wellness Center to RELEASE my medical records TO another institution. I want the SUNY Orange Wellness Center to OBTAIN my medical records FROM another institution.
RELEASE my medical records from SUNY Orange Wellness Center to:

RELEASE my medical records from SUNY Orange Wellness Center to: I authorize the release of my records I do not authorize release of my records
Name of institution, school, workplace, etc. receiving records:
Address of institution receiving records: Address of institution receiving records:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Include name of institution, work place, etc, and complete mailing address
Fax Fax - ### - ### ####
Email address of institution receiving records: (I understand that email may not be the most secure method of transmission)
OBTAIN my medical records from:

OBTAIN my medical records from: I authorize SUNY Orange to obtain my medical records I do not authorize SUNY Orange to obtain my medical records
Name of institution, school, workplace, etc. to release records:
Address of institution to release records: Address of institution to release records: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Include name of institution, work place, etc, and complete mailing address
Fax Fax - ### - ### ####
Email address of institution releasing records: (I understand that email may not be the most secure method of transmission)
Forward To:

SUNY Orange Wellness Center
115 South Street Middletown, NY 10940
FAX: (845) 341-4872
Email- immunizations@sunyorange.edu
Please upload a copy of your identification *

Attach Files

Student ID, driver's license, etc.
Draw your signature into the box below. (Note: If you are under 18 a parent/guardian must sign.)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

AUTHORIZATION TO RELEASE/OBTAIN MEDICAL RECORDS

AUTHORIZATION TO RELEASE/OBTAIN MEDICAL RECORDS

Method of Disclosure

Forward To: