Requests for Records and Forms Policy

Requests for Records and Forms Policy

Medical Records

All information contained in the medical record belongs to the patient/guarantor. The medical record itself belongs to Northeast Pediatrics and Adolescent Medicine. Please allow two (2) weeks for the processing of your request. For requests of records, the following will apply:

  • There will be a $20 fee to process the copying of your medical record regardless of its size and regardless of whether it is picked up in person or mailed via US mail.
  • A records release form must be completed and signed in order to request records.
  • Transfer of medical records to another medical practice will not be accompanied by a charge.
  • A current copy of Immunization records will be provided free of charge.
  • A current copy (well visit within 12 months) of a school or day care health certificate will be provided free of charge.

College Forms

  • There will be a $15 fee to process all college forms. Please allow two (2) weeks for completion.

In order to expedite the request, please ensure that you have had a well child exam within the last twelve (12) months, all sections have been completed that can be, and any immunizations or tests that are required have been completed or arranged for prior to submission of form.

Camp Forms 

  • There will be a $15 fee to process camp forms. Please note that if you bring more than one (1) camp form at a time, the fee will still be $15. * If a copy of the health certificate attached to the form is acceptable, there will be no charge.
  • Please note: A well child exam within the last twelve (12) months is required in order to vouch for your child's health at camp programs.
  • Over the Counter Medication requests will be completed at the discretion of your provider. Please see the form "Requests for Medications at Overnight Camps" for more details. If your child takes medication on a daily basis that we have prescribed, we will be happy to provide any appropriate medication forms required.
  • Please plan ahead when submitting camp forms as we need 7-10 days to sign and return then to you. Signed forms can be picked up at our office in the reception area.

We appreciate the time you have taken to read our forms policies. If you have any further questions, please feel free to contact our office to speak with our Office Manager.


Our Locations

Northeast Pediatrics - Main Office
10 Graham Road West - 

607-257-2188(Pediatrics)

607-257-5067(Adolescent Clinic)
Click for Map & Directions

Trumansburg Road Office
1290 Trumansburg Rd - 

607-319-5211
Click for Map & Directions

Find Us on Facebook

10 Graham Road, West Ithaca, NY 14850
607-257-2188