For former clients requesting records: 

To release your records—either to you or to a healthcare provider—we'll need you to complete, sign, and return this Medical Records Release Authorization form.

Here are the acceptable ways to do that:
- Print, complete, scan, and email it to us
- Print, complete, take a clear photo of it, and email the photo to us
- Use a PDF editor to complete & sign it, then email it to us 

***To avoid extra work and delays, please follow these instructions to ensure the form is completed properly. Incomplete forms will be returned to you for correction.
-  Write your full legal name, DOB, address, phone number, and email address in the top section
- Write who you want us to send your records to on the line that says I hereby authorize the below healthcare provider or entity:
   To yourself: Write "myself" and your email address (or fax number if you prefer)
   To a healthcare provider: Write the name of that provider or practice, their phone number, & their fax number or email address. If you don't know their fax number, please call them to ask for it. ***If their fax number or email address is not provided, the form will be returned to you as incomplete.

- The correct box (To receive my records from) is already checked for you

- Specific information to be released:
   Check the box or boxes that correspond with the records you're requesting
   If you want your complete records, please check the top box and leave the rest blank. 
   NOTE: We can only release Central Park Midwifery's records. If you need records that were sent to us by another provider, please reach out to that provider directly for instructions.

- If you have additional comments (e.g. if you don't want certain records included) please include those. Otherwise, leave that section blank.

- Be sure to sign and date the form An electronic signature is acceptable as long as it's clearly yours Return the form to us by one of the methods described above.
For email: Please send it to both [email protected] and [email protected]

For any questions, please contact [email protected]

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For other past client inquiries, please email Elaine at [email protected].

For any direct communication with Elaine, please email [email protected].

FORMER ADDRESS (no longer active)

The Schwab House building
285 West End Avenue, Suite Y2 (@73rd Street)

TELEPHONE AND FAX NUMBERS

T (347) 559-1596
Please note this number is not answered, but monitored for voicemail only.
​F (914) 462-4409

​Former telephone: 212-531-2229