Patient Forms

Forms for new patients:

Request a copy of your medical record:

If you would like us to request a copy of your medical record for yourself or a referring physician, you must fill out a written authorization. To do this, complete the form below and return it to us by (1) email a copy of the completed form to columbiaeye@columbia.edu; or (2) fax it back to (212) 305-9478; or (3)mail it to: Edward S. Harkness Eye Institute, Attn: Medical Records, 635 West 165th Street, Box 35, New York, NY 10032.

If you need additional information, please call us at (212) 342-1945.

Authorization for release of health information:

If you would like us to release any of your health information to another party, you must fill out a written authorization. To do this, complete the form below and return it to us by (1) email a copy of the completed form to columbiaeye@columbia.edu; or (2) fax it back to (212) 305-9478; or (3)mail it to: Edward S. Harkness Eye Institute, Attn: Medical Records, 635 West 165th Street, Box 35, New York, NY 10032.

If you need additional information, please call us at (212) 342-1945.

Forms for referring physicians:

To refer a patient to one of our ophthalmologists, please call (212) 305-3595 and select option “1”.

For diagnostic and imaging referrals, please complete the appropriate form below: