NEW CHILD PATIENT INTAKE FORM All parents of children under the age of 18, WHO ARE NEW TO THE PRACTICE, need to complete this patient information form and hand it to the receptioninst when they arrive for their first appointment with the doctor. (Requires Microsoft Word to view.) NY State Health Care Proxy This form allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions for yourself. Please complete and bring to CNY Family Care so it can be attached to your patient record. (Requires Adobe Reader to view. Get your free version below.) RETURNING ADULT PT UPDATE FORM ATTENTION TO ALL RETURNING PATIENTS. This form should be completed and handed to the receptionist at your next office visit. [THIS FORM IS NOT FOR PATIENTS WHO ARE NEW TO THE PRACTICE]. (Requires Microsoft Word to view.) Medical Release Form The completion of this form is required in order for CNY Family Care to release patient Health Information pursuant to HIPAA regulations. (Requires Adobe Reader to view. Get your free version below.) CNY FAMILY CARE PAYMENT POLICY This summarizes our payment policies for all patient visits...whether it is for a regular office visit or as a result of an auto accident etc. Please familarize yourself with these policies prior to your next visit to our practice. (Requires Adobe Reader to view. Get your free version below.) Notice of Privacy Practices CNY Family Care’s Notice of Privacy Practices, tells you how we may use and share your health information and how you can exercise your health privacy rights. In most cases, you should get this notice on your first visit to our office and you can ask for a copy at any time. (Requires Adobe Reader to view. Get your free version below.) NEW ADULT PATIENT INTAKE FORM All adult patients WHO ARE NEW TO CNY Family Care should complete this updated patient information form and hand it to the receptionist when they check in for their first appointment. (Requires Microsoft Word to view.) AUTH FOR TREATMENT OF MINORS This form needs to be completed by a parent or guardian on behalf of a minor under 18 years of age. It needs to be presented at the front desk when any minor comes to a scheduled doctor appointment accompanied by someone other than his/her parent or guardian. (Requires Adobe Reader to view. Get your free version below.) AUTO CLAIM FORM As a courtesy to our patients, CNY Family Care will send bills to your auto insurance carrier. This form is required in order for this process to begin. Please complete and bring to the office when you come for your office visit if you want your auto insurance to be billed. (Requires Adobe Reader to view. Get your free version below.) WORKERS' COMP FORM This form is needed to process all Workers' Compensation Claims. (Requires Adobe Reader to view. Get your free version below.)  Click here to download Acrobat Reader® software free. It enables you to view and print Adobe PDF files.