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Forms

Gannett Health Services
110 Ho Plaza
Cornell University
Ithaca, NY 14853-3101

Tel: 607 255-5155
Fax: 607 255-0269
Email

Please print out the necessary form(s). Then, complete all information in blue or black ink.

Release of health records; privacy practices

Please see patient rights forms related to your Protected Health Information (PHI) below.

Health history forms

  • Faculty and Staff Health History (pdf)
    To be used only by Cornell University employees.
  • Report of Physical History (pdf)  
    If you are seeking a general physical exam, but do not have form to complete (e.g., for a potential employer, institution of higher education, etc.), use this form. 
  • Sports Clearance (directions and pdf)
    This form must be completed by all incoming students who have been recruited as intercollegiate athletes.
  • Travel Clinic History (pdf)
    If you filled this form out via myGannett, you do NOT need to fill out a paper copy.

Department charge authorization

Protected Health Information (PHI) patient rights forms

The Health Insurance Portability and Accountability Act (“HIPAA”) gives you the right to make the following requests regarding your Protected Health Information (PHI):


Ithaca-area medical providers