Authorization to Release Medical Record Information

ROSWELL PARK COMPREHENSIVE CANCER CENTER

ELM AND CARLTON STREETS

BUFFALO, NY 14263

Dec 05, 2025

Patient's first name *

Patient's last name *

Patient MRN

Street address *

City *

County

Country

Zip code

Your Patient's Phone number * (###-###-####)

Your Patient's Email Address

Please enter the start and end dates for your record request:*

From

Please check the information to be sent:*

Please specify test and lab/pathology results:

Other information:

How would you like your records delivered?

Electronic (Email, USB, CD, Portal, Other) Home Delivery (mailed) In-Person Pickup Other

How would you like your records delivered?

Email USB CD Portal Secure Health Message other

Where do you want the information sent? - Roswell Park Comprehensive Center should provide my records to: * Self Personal Representative (indicated below)

Recipient first name *

Recipient last name *

Street address *

Recipient city *

Recipient zip code *

Your Phone Number (###-###-####)

Recipient email address

Roswell Park Comprehensive Cancer Center recognizes a patient's right under HIPAA to access copies of their health information. There may be charges associated with process a request and producing requested records.

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition:

Attach identification *

In order to verify your identity and protect your health information, please upload a clear photo or scanned copy of your driver's license or other valid government identification.

Expiration Date

Expiration Event or Condition

Signature of Patient or Personal Representative

If I fail to specify an expiration date, event or condition, this authorization will expire in 1 year.

Your Patient's Residential Address