Welcome to South Nassau
Request Your Medical Records
Here you download forms to:
To request your medical records (Protected Health Information)
- Request your medical records (Protected Health Information) (English/Spanish)
All requests are processed through Universata health care services. Only request what is necessary: You will be charged $0.75 per page for copying, as well as $1.09 processing fee. Follow these steps:
- Complete the information release form. Make sure to include:
Bring the completed form in person - with a photo ID - to:
- Patient name, address, date of birth, social security number and contact number
- Admission/treatment date
- What information should be released
- Address and the name of the individual or organization to receive the information
- Patient signature
Requests will be processed within 7 - 10 business days, in accordance with New York State law. The HIM Correspondence Dept. is open weekdays, from 9 a.m. - 5 p.m. Requests for attorneys, insurance companies, private physician offices - and any other non-patient care requests - will be handled during those hours.
- South Nassau HIM Correspondence Dept. for Emergency Room, Inpatient or Ambulatory Surgery charts/information
- The outpatient or off-site facility where services - other than those listed above - were performed.
Who is authorized to request medical records?
To file an Acknowledgement of Paternity
- Any adult, age 18 or over, or an emancipated minor may submit a signed authorization
- Legal guardians of minors who are not emancipated with proof or relationship
- Qualified persons of a deceased patient. To qualify, you must present a certified copy of the patient's death certificate as well as the signed confirmation of the distributee status form if an administrator or executor has not been appointed. If an administrator or executor has been appointed, a certified copy of the administrator estate paper is required.
- An attorney who holds power of attorney. A copy of the power of attorney - specifically authorizing the attorney to make a written request for patient information - must be provided.
- A legal representative with proof of authorized representation.
- Distributee's attorney for a deceased patient. The requestor must provide a certified copy of the death certificate, as well as a copy of the power of attorney specifically authorizing the attorney to make a written request for patient information.
If you have any questions regarding the Acknowledgement, or establishing paternity for your child, contact the Support Collection Unit of your County's Department of Social Services. If you have questions regarding the form as it relates to the birth certificate process, contact the local birth registrar where the Acknowledgement will be/is filed.
The Acknowledgement of Paternity form must be completed at the hospital.