Medical Records RequestRequesting medical records of one of our patients is simple. Fill out the Hippa Records Request form and submit it to us through our website or by fax.

Download Hippa Records Request Form Here

Once you have completed the request form, you have two options to submit the form to us.

  1. Submit your completed form below.
  2. Fax your completed form to us at 716-342-2523.

Once we receive your request, we will contact you shortly to confirm your request.

All fields marked with an (*) are required.

REQUESTER INFORMATION

Requester Name(*)
Please tell us the Doctor's name.

Phone Number(*)
Please enter your phone number.

Email(*)
Invalid email address.

PATIENT INFORMATION

First Name(*)
Please enter your first name.

Last Name(*)
Please enter your last name.

ADDITIONAL INFORMATION

Hippa Records Request Form(*)
Please submit your completed Hippa Records Request Form.

(accepted file types: pdf, doc, docx) (maximum file size: 2MB)

Questions / Comments
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Human Verify
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Monday | 9:00 AM - 5:00 PM
Tuesday | 9:00 AM - 5:00 PM
Wednesday | 9:00 AM - 5:00 PM
Thursday | 9:00 AM - 7:00 PM
Friday | 9:00 AM - 5:00 PM
Saturday | CLOSED
Sunday | CLOSED

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