Adolescent-Medicine-Request-Form

503 Grasslands Road Valhalla, NY 10595 P: 914-304-5288 (adol. Med) P: 914-304-5254 (ped gyn) F: 914-345-1755

MEDICAL RECORDS REQUEST INSTRUCTIONS Adolescent Medicine Gilberto Velez-Domenech, MD Wallace Jenkins, MD Marcia Nackenson, MD Martha Arden, MD Pediatric/Adolescent Gynecology Monique M. Regard, MD Mariel Focseneanu, MD

PLEASE NOTE: RECORDS WILL BE COMPLETED 10 BUSINESS DAYS AFTER REQUEST IS RECEIVED NO EXCEPTIONS

For instructions on how to obtain medical records for yourself or a healthcare provider, please visit www.cwpw.org.

1. Type Adolescent Medicine/Pediatric & Adolescent Gynecology in the specialty field. 2. Select Medical Records Request Authorization 3. Print, fill out, & sign the authorization form and return to us via:

Fax : (914) 345-1755 or mail to our office Our mailing address

Children’s & Women’s Physicians of Westchester 503 Grasslands Road – Suite 200 Valhalla, NY 10595 Attention: Medical Records

Please make sure that you include all information with the form or the request cannot be completed: ______Name ______address where you would like records sent to i.e. home or healthcare provider

Fax number: (______) ______- ______Contact number: (______) ______-______

Thank you

CHILDREN’S & WOMEN’S PHYSICIAN’S OF WESTCHESTER 503 GRASSLANDS ROAD VALHALLA, NY 10595

IF YOU ARE USING A GPS, PLEASE USE 505 GRASSLANDS ROAD.

TACONIC PARKWAY SOUTH to Sprain Brook Parkway South to Eastview Exit / Route 100 C. Turn left onto NY 100 C / Grasslands Road. Continue to follow Grasslands Road to 503, approximately 1/4 mile on the right.

ROUTE 684 SOUTH to Saw Mill River Parkway South to Exit 26 - Sprain Brook Parkway South to Eastview Exit / Route 100 C. Turn left onto NY 100 C / Grasslands Road. Continue to follow Grasslands Road to 503, approximately 1/4 mile on the right.

SAW MILL RIVER PARKWAY SOUTH to Exit 26 - Sprain Brook Parkway South to Eastview Exit / Route 100 C. Turn left onto NY 100 C / Grasslands Road. Continue to follow Grasslands Road to 503, approximately 1/4 mile on the right.

SAW MILL RIVER PARKWAY NORTH to Exit 21 East. Take the ramp on the right for Route 119 East toward Elmsford. Turn right onto Route 119 / East Main Street / Tarrytown - White Plains Road. Turn left onto Route 9A. Take the ramp on the right and follow signs for Route 100 C. Turn right onto Route 100 C / Grasslands Road.

TAPPAN ZEE BRIDGE TOWARD WESTCHESTER TO I 287 EAST to Exit 4. Make a left onto Knollwood Rd. Follow Knollwood Rd., then make a left onto Grasslands Road / 100 C. Go down to the light, make a u-turn, go back up on Grasslands Rd. and look for 503.

SPRAIN BROOK PARKWAY NORTH To the exit toward Rt. 100 C South / Rt. 100 / Eastview. Make a right onto Grasslands Rd.…………………… ……………………… .

I 95 (NEW ENGLAND THRUWAY) NORTH …………… ……………………………… . to 287 West. Stay in right lane and take next exit, Exit 3 - Sprain Brook Parkway North. Stay in left lane (Taconic Pkwy North) and take first exit Eastview Ave. Turn Right at exit and make immediate right at 503 Grasslands. ………………………………………………………………….

……………………………………………… I 95 (NEW ENGLAND THRUWAY) SOUTH …………………. …………………………………………… to 287 West. Stay in right lane and take next exit, Exit 3 - Sprain Brook Parkway North. Stay in left lane (Taconic Pkwy North) and take first exit Eastview Ave. Turn Right at exit and make immediate right at 503 Grasslands. ……………………………………………

MERRITT PARKWAY SOUTH ………………….…………………………………………………………… Becomes Hutchinson River Parkway South. Take the Westchester Ave. Exit, Exit 26 West toward I-287 West. Stay in right lane and take next exit, Exit 3 - Sprain Brook Parkway North. Stay in left lane (Taconic Pkwy North) and take first exit Eastview Ave. Turn Right at exit and make immediate right at 503 Grasslands.

IF YOU ARE USING A GPS, PLEASE USE 505 GRASSLANDS ROAD.