Release of Medical Records Form

You must complete this form in order for RAWNY to disclose or release the your protected health information to another person or organization. You may download and complete the form below and return it to our office to issue the release of medical records.

Patient Authorization for Release of Medical Records


Medical Record Amendment Request Form

As a patient, you have a right to request an amendment (correction/changes) to your medical record if you believe the information is incorrect or incomplete. In order to make this request, you will need to submit a completed Amendment Request form. Download this form below and fill out completely. In the “Dispute and Requested Correction” field, please completely and accurately describe how the disputed documentation is incorrect and/or incomplete. Then write exactly what you think the documentation should state to be accurate and/or complete.

You will be notified of the acceptance or denial of your request within 60 days of its receipt. If there is a delay, you will be notified in writing on a one-time 30 day extension. The notification will include a reason for the delay and the date by which the action will be completed. If your request has been accepted and you have authorized Retina Associates of Western NY, P.C. to disclose any amended information, we will send copies of any amended or corrected information to the parties who previously received records and the one(s) you have indicated on the request form. The Amendment Request and any additional documents related to the request will become a part of your permanent medical record and may be disclosed to future requestors as it relates to the subject of the amendment.

If your request has been denied, you have the right to submit a written statement of disagreement to our office manager at You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services.

Medical Record Amendment Request


Patient Assistance and Support Programs

For co-pay and support program applications please visit our Financial Policy page.

Ocular Inflammatory Disease Review of Systems Questionnaire

This form is a specific health history questionnaire for patients for patients with suspected ocular inflammatory disease. It is to obtain facts pertinent to your past and present health. You only need to fill out this form if you have been instructed to do so by our office. Please bring the completed form with you to your appointment.

Ocular Inflammatory Disease Review of Systems Questionnaire


Patient Satisfaction Survey

Coming soon