������Ƶ

You may request copies of your medical records by completing a Release of Protected Health Information form. This form is on the Decker Student Health Service’s patient portal. Follow these steps to submit a Release of Protected Health Information form:

Step 1: Access the Release of Protected Health Information form

• Browse to the .
• Sign in using your ������Ƶ username and password.
• Once on the portal, click on the “Upload” icon located on the menu to the left.
• Scroll down to the "Upload Documents" section and look for
  • • Release of protected health information – Health services/psychiatry OR
    • Release of protected health information – University Counseling Center
• Click on the "Download" icon. The Authorization for Release of Protected Health Information will open up on your screen as a PDF document.

Step 2: Complete the form

• Carefully complete all of the requested information within each section of the Release of Protected Health Information form. Improperly completed or incompletely filled out forms will have to be re-submitted by you.
• Please make sure you complete all of the personal information, such as Patient Name, DOB, B#, Legal Name (if different), a phone/cell number you can be reached at in the event we have any questions, as well as your home address.
  
  • • Section 6: Put in ALL OF THE REQUESTED INFORMATION about the person/office who you wish to release your protected health information. This includes the full name, address, phone number, and fax number. The information for the Decker Student Health Services Center is:

Decker Student Health Services Center 
������Ƶ 
4400 Vestal Parkway East 
Binghamton, NY 13902 
Phone: 607-777-2221  
Fax: 607-777-2881 

Decker Student Health Services Center – Psychiatry
������Ƶ 
4400 Vestal Parkway East 
Binghamton, NY 13902 
Phone: 607-777-3711  
Fax: 607-777-5280 

University Counseling Center 
������Ƶ 
4400 Vestal Parkway East 
Binghamton, NY 13902 
Phone: 607-777-2772  
Fax: 607-777-2708 

• • • Section 7: Put in ALL OF THE REQUESTED information about the person/office who you want to receive your protected health information. This includes the full name, address, phone number, and fax number.
    • Section 8: Indicate the reason this information is being released. If you want the office releasing the information to be able to speak with the office receiving the information, please place an "X" in the box "Other Purpose" and provide details.
    • Section 9:
      • Indicate an expiration date for the release, if desired. If not indicated the release will be valid for one year from the date of the signature.
      • Initial the types of records you want released. IF THERE IS NO INITIAL, THE RECORDS WILL NOT BE RELEASED. For example, if you indicate you want all your health records sent, but do not initial HIV/AIDS-related information, all HIV/AIDS-related information will be redacted.
• Save the completed form on your device.

Step 3: Upload the completed form to the patient portal

• Go back to the “Upload” icon, located on the left side of the menu.
• Scroll down to the "Upload Documents" section and look for
  • • Release of Protected Health Information – Health Services/Psychiatry OR 
    • Release of Protected Health Information – University Counseling Center
• Click the "Select File" icon for the office you would like to upload your release to (Release of Decker Health/Psychiatry or University Counseling Center)
• One you choose the file from your device, it will be visible just to the right of the "Select File" icon
• Scroll down to the bottom of the "Upload Document" section and click on the blue icon button labeled "Upload."
• Once you click the blue "Upload" icon, a box will pop up stating "Document Upload" and "Thank you for submitting your documents."