Medical Records Release Authorization Form

The following are provided to authorize the release of your medical records. From the options below, please print the appropriate form, fill out, and fax to the recipient indicated:

To have records SENT TO Downtown Primary Care
(These are records originating from another doctor or medical facility). Fax completed form to the provider.

 

To have records SENT FROM Downtown Primary Care
(These are records going to another doctor, or to the patient). Please be aware there is a fee to provide patients with a copy of their medical records. Fax completed form to Downtown Primary Care.

 

Physician Referral Request

If your insurance requires a referral or pre-authorization to see a specialist or schedule a procedure, please access our Patient Portal, and send a secure message to our medical assistant with the following information:

  • Patient's Name, Phone Number, and Insurance Plan
  • Physician's Name, Phone Number, Fax Number, and Insurance ID Number
  • Date of Appointment
  • Reason for Appointment
  • any Additional Comments
  • If you are unable to make the request online, please call our main office number and follow the prompts to leave a message on our dedicated referral voicemail.

Referrals require two business days to process, unless emergent. Some new referrals require an office visit.

Please be aware that depending on your insurance, you may need a primary care referral even for tests ordered by a specialist.

 

Prescription Refill Request

Every effort will be made to write prescriptions and refills at your office visit. Please access our Patient Portal, and send a secure message to our medical assistant with the following information:

  • Patient's Name, and Phone Number
  • Pharmacy's Name, Phone Number, and Fax Number
  • Name of Medication
  • Dosage of Medication
  • any Additional Comments
  • If you are using a mail order pharmacy, please provide the required forms. In the event of a lost prescription, we will make additional copies available at our front desk.

Prescription refills require two business days to process, unless emergent. Some prescription refills require a follow-up office visit.

All new or controlled substance prescriptions require an office visit.

 

Health Links

General Health Information:
http://www.mayoclinic.com
http://patients.uptodate.com

Travel Medicine:
http://wwwn.cdc.gov/travel

New York City Department of Health:
http://www.nyc.gov/html/doh

New York University Medical Center:
http://www.med.nyu.edu