Medical Records Requests
Ellis Medicine has partnered with Verisma Systems, Inc. to process medical record requests. Verisma, a proven leader in the industry of Release of Information technology, securely and confidentially manages patient medical records requests on behalf of Ellis Medicine.
Ellis Medicine protects the use and confidentiality of your medical record. By completing the forms below with your signature, you can securely access your medical record and your request will be processed.
Please Note: A per-request service charge of $6.50 may apply when requesting a copy of your records.
Ways to Request Your Medical Records
I. Online Request Form with Verisma - the fastest way to request your medical records.
> Request Your Records Here
> Request Records for an Ellis Patient Here (if you are the parent or legal guardian)
II. Download or Print forms
>Patient Request for Access to Protected Health Information - Use this form when you want a copy of your medical records or the records of your child or person for whom you are the legal guardian.
>Authorization for Release of Information - Use this form when you want us to send your medical records to a third party, for example a new health care provider.
Submit completed forms by mail, fax or email as listed below:
Attn: Health Information Services
Mail Code: 1768
1101 Nott Street, Schenectady, NY 12308