Medical Release Forms


  • Write clearly in black or blue ink.
  • The patient's name should be the name of the patient at the time of treatment.
  • Specify as best you can the dates or time periods of the records you need.
  • Specify the reason for the request (i.e.: going for a second opinion, moving, transferring out of our care, etc.)
  • No HIV results will be released unless the specific HIV authorization form is completed. Call the office to get a separate form.
  • Only a signed and completed authorization will be considered.
  • ***Allow at least 10 business days to process your request. ***NO EXCEPTIONS!!***
  • There is a New York State regulated fee for the copying of your medical records of $0.75 per page. This can be found in Sections 17 and 18 of Public Health Law (PHL), Laws of 1991, Chapter 165, sections 48 and 49. Postage charge is additional.
  • Failure to complete the credit card authorization may delay processing. For credit card authorization, please call the office at 516-365-6167 and have the following information available: Patient Name, Address, Credit Card Number, Expiration Date, 3-Digit Security Number (on the back of the credit card), and Type of Credit Card.

For medical release forms TO Dr. Simhaee, click here.
You may fax the forms to 516-365-6308 or mail them to:
Dr. E. Jacob Simhaee
1201 Northern Blvd., Suite 300
Manhasset, NY 11030

For medical release forms FROM Dr. Simhaee, click here

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