Directory information, not recipient confirmation. Fax numbers can change and differ by department, location, form, or plan. Confirm this destination directly with Allentown Pediatric & Adolescent Medicine, LLP before sending sensitive documents. FaxFlow is not affiliated with this organization.
Allentown Pediatric & Adolescent Medicine, LLP fax number
(716) 332-4474
Release of Records
Used for: Medical records transfer/authorization for release of protected health information to Allentown Pediatric & Adolescent Medicine
Fax destination details
- Department
- Release of Records
- Purpose
- Medical records transfer/authorization for release of protected health information to Allentown Pediatric & Adolescent Medicine
- Form
- Individual Authorization for the Use and Disclosure of Protected Health Information — INDIVIDUAL AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
- Address
- 1775 Niagara Street, Buffalo, NY 14207
- Voice phone
- (716) 332-4472
- Website
- Visit organization website
Before you send
- Confirm that this exact department handles your document or request.
- Check the organization website or call its main line for the current fax number.
- Include a cover sheet and any case, member, claim, or form reference required.
- Keep the delivery confirmation with your submission records.
Fill in patient name and date of birth, provide the previous doctor's name and address, specify the recipient (Allentown Peds), indicate which records to release, and sign/date. Optional boxes may request HIV/chemical dependency/mental health records. Revised 3/2025.
Official form instructions are published as a downloadable file on the organization's website.
Sources and verification
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