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Northeast Pediatrics & Adolescent Medicine fax number
(607) 266-0909
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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.
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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.
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