Authorization to Release Medical Record Information

Instructions: Download and print form, fill in information return to us via mail or fax:

Roswell Park Cancer Institute
c/o Health Information Department
Carlton Building Rm 105
Buffalo, NY 14263
FAX: 716-845-8394

Requests will be processed in 7-10 days of receipt. Please note there may be a small copy charge. If you have any questions please contact our Release of Information staff at 716-845-5990 or 716-845-8729.