Authorization for IFP to obtain patient medical records

We are asking patients who participate in the Letrozole Follow-Up Study to provide permission for IFP to obtain copies of your medical records so we can properly analyze and validate the study findings. All records will remain confidential and be used solely for purposes of research.

To authorize IFP to contact your health providers to obtain copies of your medical records, please do the following:

• Click Medical Records Release.
• Print out the form.
• Fill out all information.
• Be sure to SIGN it.
• Mail or fax the completed form to IFP. (Address below)

Note: Do not e-mail the form. Mail or fax only, to:

Institute for Fertility Preservation
21 E. 69th Street
New York, NY 10021

Phone: (212) 994-4400
Fax: (212) 994-4499