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. 

About Medical Records

Health and immunization records submitted to or generated by Student Health Services are held on file for 7 years from the date of submission.

Information About Students Over the Age of 18

Consent is required from students 18 years old and over, before Student Health Services can release any medical information to another person.

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.

Processing Time

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.

Submissions of Medical Records Release

We are currently accepting requests for medical records via email. Please complete the consent form and submit via email.  If you are requesting immunization records only, we can release these via mail, fax or email.  However, we are not able to email your entire medical record, so please provide a fax number or mailing address to which we can send those records.

For the best experience use a non-mobile device.

To Submit this Form, or Get Help

University at Buffalo
4350 Maple Rd
Amherst, NY 14226

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