Directory information, not recipient confirmation. Fax numbers can change and differ by department, location, form, or plan. Confirm this destination directly with Northeast Pediatrics & Adolescent Medicine before sending sensitive documents. FaxFlow is not affiliated with this organization.
Northeast Pediatrics & Adolescent Medicine fax number
(607) 266-0909
Medical Records / Records Release
Used for: Medical records release; HIPAA authorization (OCA Form No. 960) to release health information
Fax destination details
- Department
- Medical Records / Records Release
- Purpose
- Medical records release; HIPAA authorization (OCA Form No. 960) to release health information
- Form
- OCA Official Form No. 960 — Authorization for Release of Health Information Pursuant to HIPAA
- Address
- 10 Graham Road West, Ithaca, NY 14850
- Voice phone
- 607-257-2188
- 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.
HIPAA-compliant authorization form that allows release of the patient's health information either in full or a date range, with optional disclosures for sensitive information (e.g., HIV-related, alcohol/drug, mental health). It explains how to revoke authorization, and that the recipient will be named in Item 8. The form may be completed online or downloaded and signed.
Official form instructions are published as a downloadable file on the organization's website.
Sources and verification
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