Patient Forms

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 complete authorization online. To do this, please visit the following website to complete the authorization form online, visit https://vra.recordjacket.com/columbia.

If you have Connect patient portal, please login and request your records directly through the portal. If you have not signed up for the patient portal, please click here for instructions. 

If you need additional information, please call us at (212) 305-8255.

 

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, you must complete authorization online. To do this, please visit the following website to complete the authorization form online, visit https://vra.recordjacket.com/columbia.

If you need additional information, please call us at (212) 305-8255.

 

Forms for referring physicians:

To refer a patient to one of our ophthalmologists, please call (212) 305-3595 and select option “2”.

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