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Authorization to Release Health Information

Patients or their legal representatives, please use this form to provide authorization to release or obtain your health information. For more information about this form or obtaining copies of your medical records, or to contact our Health Information Management department, please visit our Medical Records page.

Submitting Your Form

Submit your completed form by mail to the appropriate address below:

For Faxton St. Luke's Healthcare related inquiries:

Faxton St. Luke's Healthcare
Health Information Management (HIM) Department
PO Box 479
Utica, NY 13503

For St. Elizabeth Medical Center related inquiries:

St. Elizabeth Medical Center
Health Information Management (HIM) Department
2209 Genesee Street
Utica, NY 13501

(See our Provider List to determine if your Medical Group office is an FSLH or SEMC affiliated location.)