I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:. If you would like us to release any of your health information to another party, you must fill out a written authorization.Medical Record Request. Collect medical authorization online with a medical authorization form. Easy to customize and share. Our Medical Authorization Form is straightforward to fill out, making the process quick and hasslefree. Listed below are brief descriptions of common types of child care programs in New York State. How do I obtain my medical record? You can request medical records in several ways: Complete the online patient authorization for release of information. It was called the Advance Healthcare Directive.