Doxy Telehealth - How to check-in in for your video virtual visit with your doctor

New Patient Mental Health History Form - For patients scheduled to see Shirley Mazourek, LCSWR (clinical social worker) only

New Patient Mental Health History Form - For patients scheduled to see Dr. Marlon Koenigsberg (psychologist) only

Authorization for Release of Health Information

Use this form to request medical records. Fax or mail to the office you normally visit.

Fax Numbers:
Amherst: 716.932.7465
Conventus: 716.323.0585
Sheridan: 716.835.9876

Please allow up to 30 days, although we generally process within 2 weeks.

If you are changing your PCP (Primary Care Provider), please contact your insurance company with the name of your new provider.

Medicare Annual Well Visit Health Risk Assessment (HRA)

Preoperative Visit Questionnaire - Please complete and bring to your pre-operative visit at our office

HIPAA Contact Form

New York State Health Care Proxy Form (more info available at NYS Advance Care Planning)

Re-establishing Form

UBMD Primary Care Financial Policy

Telepsychology Consent Form - For patients scheduled to see Dr. Koenigsberg (psychologist) for Telepsychology visit only