Authorization to Release or Obtain Health Records Form

Allow your medical records to be released by Student Health Services, or allow another health care provider to release your records to Student Health Services. Please note that it may take up to two weeks to process your request for release of information, depending on the current volume of requests.

About Medical Records

Health and immunization records submitted to or generated by Student Health Services are held on file for 10 years.

Information About Students Over the Age of 18

In accordance with HIPAA (Health Insurance Portability and Accountability Act), if a patient is 18 years of age or older we cannot release any medical information to a parent, spouse, instructor, employer or anyone else other than the patient him/herself. Patients who would like Student Health Services to verify an appointment or discuss diagnosis and treatment with anyone other than themselves must sign an authorization consent form during their visit. This consent pertains to that day’s appointment only; a new release form must be signed at each visit.

Only for Health Care Provided by Student Health Services

If other individuals or agencies have provided confidential information to Student Health Services, you cannot use the authorization form to re-release this information. For copies of medical records that came from another individual or agency, please contact that original individual or agency directly.

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To Submit this Form, or Get Help

University at Buffalo
Michael Hall, 3435 Main Street, South Campus
Buffalo, NY 14214

Phone: (716) 829-3316; Fax: (716) 829-2564