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Patient Forms

In order to help provide you with the best possible care, we have provided some general information as well as answer some questions prior to your visit with us. If you have further questions, please do not hesitate to call our office during regular business hours or bring any questions you may have to your next appointment.All forms are in pdf format and will require you to have Adobe Reader to view and print. You may download Adobe Reader for free at www.adobe.com
Insurance

We participate in most major medical insurance plans in the Buffalo and Rochester area. We also accept No-Fault (MVA), Workers’ Compensation and Medicare. You are responsible for providing us complete and accurate billing information. If you have any changes in your insurance, you must notify us immediately. Please be aware that your insurance may not always cover the entire bill and you may have to pay deductibles. You are responsible for copayments at the time of service. If you have an HMO which requires a referral from your family physician, it is necessary for you to arrange for the referral prior to your appointment.
Workers’ Compensation
You must bring your employer’s name, address and phone number as well as their insurance carrier’s name, address and phone number to your initial appointment in order to properly bill. We also ask that you provide your private insurance information in the event that your claim is denied by Workers’ Compenstion. This includes obtaining a referral if you have an HMO. You may download and print the following form to complete and bring to your initial visit.

Workers’ Compensation Information Form


Motor Vehicle Accident (No-Fault)

You must bring your automobile insurance name, address and phone number to your initial appointment in order to properly bill. If the claim is going under another person’s automobile insurance, you will need to obtain that information. We also ask that you provide your private insurance information in the event that your claim is denied by MVA/No-Fault. This includes obtaining a referral if you have an HMO. You may download and print the following form to complete and bring to your initial visit.

Motor Vehicle Accident Information Form


Disability Forms

It usually takes 7-10 business days to complete your disability forms. We charge $5.00 per form every time a form is requested. If the claim is under No-Fault or Workers’ Compensation, there is no charge for completing forms. Payment is required when the form is dropped off. Your portion of the form needs to be completed as we will not give forms back. They are submitted directly to the insurance company. For a timely return of your form, please provide accurate and completed address or fax number of your insurance company.


Medical Records and Reports

Your medical records and x-ray fiilms/images are the property of our office and are held in strictest confidence. We must have your written authorization, signed by you, in order to release information. There may be a charge for copying records and/or films which must be paid in advance. You may download and print the following form to complete and return to the office in order to obtain records or to have your records sent to another provider.

Medical Records Release Form


X-Ray Films and/or Digital Images

If you have had x-ray films and/or digital images done at the Emergency Room or by another physician, it is necessary that we have access to these films and/or digital images at your appointment. Contact our office regarding whether you will need to bring copies with you or not. If you do need to bring copies with you, you must contact the facility the films and/or digital images were done at in order to obtain copies for your appointment.

Regarding x-ray films done in our office prior to 12/31/07: If you need to borrow x-rays films from our office, a $20.00 refundable deposit is required. After the films have been returned to our office, your deposit will be given back to you.

Regarding digital images done in our office after 1/1/2008: A copy of the images can be made for you at no charge and do not have to be returned to the office.

You may download and print the following form to complete and return to the office in order to obtain x-ray films and/or digital images or to have them sent to another provider.

X-Ray and/or Digital image Relase and Deposit Form


New Patient Forms

If you are a new patient with an appointment at our office, you may download the following forms instead of having them mailed to you at home. In order to help with your appointment, it is best to complete the forms and mail back to our office so that we may get your information into our computer system prior to your visit. If you have any problems or questions, please do not hesitate to contact our office.

Patient Information Form

Medical History Form

Drug Policy form

HIPAA Privacy Notice

The Patient Information, Medical History and Drug Policy Forms must be completed, signed and returned to the office prior to your being seen by the doctor. The HIPAA Privacy Notice will be signed electronically in the office at your first visit.
Established Patient Forms
If you are an already established patient with us, you may be asked to update some information for us. The instructions are the same as for New Patient Forms above.

Patient Information Update Form