UBMD Pediatrics Medical Records Request Platform

UBMD Pediatrics Medical Records Request Platform

Welcome to the UBMD Pediatrics Online Medical Records Request Service. Our platform is designed to help you access your medical information quickly and safely. To facilitate a seamless process, please prepare your personal and provider information in advance. Start by choosing the type of records you need: UBMD Pediatrics Outpatient Clinic Records or John R. Oishei Children's Hospital (OCH) Hospital Records & Tests.
UBMD Pediatrics Outpatient Clinics (Conventus, Amherst)Golisano Children's Hospital of Buffalo (GCH), (formerly known as Oishei Children's Hospital) Records & Tests

UBMD Pediatrics Medical Records Request Platform

Welcome to UBMD Pediatrics online Medical Records Request platform. We're here to assist you in obtaining the information you need, securely and efficiently. Please have your necessary personal and provider details ready to ensure a smooth experience. Before you begin please review the Preparation Checklist below to ensure you have all the right information to complete your autorization for release of Health Information pursuant to HIPAA

Preparation Checklist:

To ensure a smooth and efficient process when completing your medical records request form, it's beneficial to have the following information at hand:

Patient Identification: Be ready with your full legal name (including any suffixes), date of birth, and social security number, as these are essential for verifying your identity and locating your medical records.

Patient Contact Information: Have your complete address, including the city, state, and ZIP code, as well as your contact numbers, so that we can reach out to you if necessary.

Provider, Legal and Third-Party Details: Know the name and address of the healthcare provider or the entity (attorney or the governmental agency you are authorizing)for which you are requesting records. Having their phone and fax numbers will also be important for any direct communications required.

Authorization Credentials: If you are not the patient, ensure you have the proper authority or relationship documentation to request records on behalf of the patient.

Medical Record Request Specifics: If seeking records for a specific period, make sure you know the exact dates.

Authorization Expiry Date: Decide upon an expiration date for the authorization to release your medical records, ensuring it aligns with your needs and legal requirements (if applicable)
Choosing John R. Oishei Children's Hospital means your records are directly handled by the hospital and necessitate a distinct request procedure.

To access your hospital records and tests, you'll need to go through the hospital's Health Information Management Department.

For comprehensive guidelines on requesting medical records and additional details about the process, please refer to the John R. Oishei Children's Hospital Medical Records page at https://www.ochbuffalo.org/care-treatment/Medical-Records

Please select the category that best describes your medical records request. Your selection will ensure we handle your request appropriately and efficiently.
Request for Clinical Notes (Personal Use): Choose this option if you are a patient seeking access to your clinical notes for personal reference or use.Medical Records Request (Provider-to-Provider): Choose this option if you are a healthcare provider requesting medical records from another provider for ongoing patient care.Third-Party or Legal Requests: Choose this option if you represent a third-party organization or a legal entity, such as an attorney, requiring medical records for authorized purposes.
You Selected "Patient Requests for Clinical Notes for Personal Use"

Terms of Processing

Processing Time: Minimum of 30 days from receiving a completed, signed medical record release form and a copy of the patient's driver's license.

Collection Method: Patients are notified post-30-day period and must return to Conventus to collect their records.

Delivery: Clinical notes are not mailed to the patient.

Proccessing Charge: There is a charge of .75 per page

By clicking 'Agree & Continue,' you acknowledge that you have read, understood, and agreed to these terms. This will enable us to process your request efficiently and in compliance with relevant regulations.
You Selected "Provider-to-Provider Medical Records Request"

Terms of Processing

Processing Time: Minimum of 10 days to 2 weeks from receipt of a complete, signed medical record release form from the physician’s office.

Delivery: Kate faxes the records to the requesting provider from fax number 716-323-0293.

Patient Option: Patients may request fax delivery of their medical records directly to a specified provider or practice location with no charge

By clicking 'Agree & Continue,' you acknowledge that you have read, understood, and agreed to these terms. This will enable us to process your request efficiently and in compliance with relevant regulations.
You Selected "3rd Party Requests/Attorney Requests"

Terms of Processing

Processing Time: Will expedite as soon as possible

Delivery:

Processing Fee: Per NYS Guidelines there is a charge of .75 per page (Invoice to be sent)

By clicking 'Agree & Continue,' you acknowledge that you have read, understood, and agreed to these terms. This will enable us to process your request efficiently and in compliance with relevant regulations.

Patient Identification & Contact Information:

Directions: It's important to enter the Patient's full legal name, including any suffixes, along with your date of birth and social security number to ensure we correctly identify you and retrieve your medical records. This includes, patient's full address with the city, state, and ZIP code.
Preferred Contact Email*
example@example.com
Patient Name*

First NameMiddle InitialLast NameSuffix
Patient Date of Birth*

MonthDayYear
Date
Social Security Number
Required only if you have Medicaid:
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code

Provider, Legal and Third-Party Details:

Directions: It's important to enter the name and address of the healthcare provider or the entity (attorney or the governmental agency you are authorizing)for which you are requesting records. Having their phone and fax numbers will also be important for any direct communications required.
Name and Address of person(s) or category of person to who this information will be sent:*

Provider/Medical Office Name

Street Address

CityState

Zip Code
Provider/Medical Office Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Provider/Medical Office Fax Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name and address of health provider or entity to release this information
UNIVERSITY @ BUFFALO PEDIATRICS ASSOC. INC. - 1001 MAIN ST, BUFFALO, NY 14203 - 5TH FLOOR MED REC.

Details of the Records to Release:

Directions: To complete this section:

Please specify "Medical Records For a Specific time Period, if you are requesting records from a particular time frame. Ensure that the relevant start and end dates in the 'Medical Record From' and 'Medical Record To' fields is accurately completed.

For a comprehensive release of all medical records, select the option for 'Entire Medical Records.'

Should you require different documents, provide a clear description of the records needed.
Medical Records For a Specific time Period - If a patient wishes to authorize access to their entire medical record for a specific time period, please enter the relevant start and end dates in the 'Medical Record From' and 'Medical Record To' fields provided below.Entire Medical Records-including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providersOther
Medical Record from*

MonthDayYear
Date
Medical Record to*

MonthDayYear
Date

Authorization to Discuss Health Information:

Directions: To complete this section:

Initial to authorize UNIVERSITY @ BUFFALO PEDIATRICS ASSOCIATES to discuss your health information with the listed attorney or agency. This includes the reason for release of information whether this is at the Individual's Request or another specified reason.
YesNo
Initials*
Attorney/Firm Name or Governmental Agency Name*
I authorize
UNIVERSITY @ BUFFALO PEDIATRICS ASSOCIATES

Authorization Credentials:

Directions: To complete this section ensure the following are completed:

Authorization Credentials: If you are not the patient, ensure you have the proper authority or relationship documentation to request records on behalf of the patient. This includes the reason for release of information whether this is at the Individual's Request or another specified reason.

Authorization Expiry Date: Decide upon an expiration date for the authorization to release your medical records, ensuring it aligns with your needs and legal requirements (if applicable)
At request of individualOther
Date or event on which this authorization will expire*
The person filling out the form may designate an event such as “at the conclusion of my court case” or provide a specific date amount of time, such as “3 years from this date”.
If not the patient, name of person signing form*
Authority/Relationship to sign on behalf of patient*
Authority/Relationship - Other*

Sign to Consent:

Directions: To complete this section verify the correctness of the provided information and sign the form to authorize your request.
All items on this form have been completed and my questions about this form have been answered. Signature of patient or representative authorized by law.

HIPAA and New York State Law Acknowledgment:

As I, or my authorized representative, request the release of health information as outlined on this form, I acknowledge and understand that:

Any disclosure may include information on ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV* RELATED INFORMATION if I initial the specified line in Item 9(a).

If the release includes HIV-related, alcohol or drug treatment, or mental health information, it cannot be redisclosed without my consent unless allowed by law, and

I can request a list of entities that may receive my HIV-related information without my consent.

I can revoke this authorization at any time by writing to the listed health care provider, barring actions already taken based on this consent.
Signing this form is voluntary, and my refusal to sign will not affect my treatment, payment, health plan enrollment, or eligibility for benefits.
The information released may be redisclosed by the recipient and may not be protected by law if redisclosed.

This form does not permit discussions about my health information or medical care with anyone apart from the attorney or agency indicated in Item 9(b).
Signature*

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Please select the category that best describes your medical records request. Your selection will ensure we handle your request appropriately and efficiently.