Records Request

The William George Agency for Children’s Services
Records Request Form

Instructions: Do not submit confidential or sensitive information through this form (e.g., social security number). Once this form has been submitted, you will be contacted by a staff member who can best complete your request. Kindly allow 48 hours for routine requests. For records requests from WGA other than those listed below, please contact the main switchboard at 607-844-6460.

All requests for copies of clinical and/or medical records from WGA must also include a completed and signed Authorization for Release of Health Information From WGA form. Click here to download and get started on that form while your request is being processed.

Please do not use this form for:

school-related requests (e.g., a transcript, graduation verification, immunization or other. For such requests, please complete the form on the GJR UFSD website.
staff-related requests (e.g., employment verification). Please email your request directly to HR instead.

Fields marked with an * are required

Please enter the name that you had when you were at The Agency

Phone (XXX-XXX-XXXX)

Date of Birth (MM/DD/YYYY)

What record(s) are you requesting? (You can select only one category below at this time. If you are looking for information in other categories, please let us know in the Special Information field below.

Residential Medical Clinic (see note under Instructions above) Vocational Performance Evaluation Form(s) VanClef Substance Use Disorder Treatment Clinic Records Other (please specify in special information area)

Where would you like your records sent?

City

State

Zip Code

Special Information

Who We Are

A Holistic Approach

Careeers

Thank you.