HIPAA FORM A

This form is used when a patient seeks to authorize the release of his/her medical records FROM CNY Family Care to themselves or another Physician/ Practice/ Hospital. If you need help filling out this form, please call our Medical Records Department: (315) 463-1600 Option #4.

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HIPAA FORM B

This form is used when a patient seeks to authorize another Physician/ Practice/ Hospital to send his/her medical records TO CNY Family Care. If you need help filling out this form, please call our Medical Records Department: (315) 463-1600 Option #4.

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Authorization for Medical Treatment of Minors (PDF)

Allows parents to authorize another person to approve or deny medical treatment for their minor child under 18. A parent or guardian must accompany any minor
under age 18 to every office appointment as consent is required by a parent or guardian for the child to receive testing and/ or immunizations. When a parent or guardian cannot attend the scheduled appointment, this form must be presented to the front desk authorizing the person bringing the child to the appointment to consent for treatment for that child.

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NY State Health Care Proxy Form (PDF)

The Health Care Proxy allows you to appoint someone you trust — for example, a family member or close friend to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes. For this form to be valid, you will need to appoint a health care agent, and that health care agent cannot also be a witness who signs on this form. You will need to have two witnesses sign this form to be valid.

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ADOLESCENT NEW PATIENT HISTORY FORM (PDF)

For adolescent new patients aged 13-17, their parent(s)/guardian(s) are NOT provided patient portal access. Their parent/guardian must call 315-463-1600 and speak
to CNY Family Care’s office staff for their child to become a new patient. This form is for adolescent parents to print if they misplaced the form we mailed to their child.

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ADULT NEW PATIENT HISTORY FORM (PDF)

To become a new adult patient, please be aware that we will REQUIRE you to use CNY Family Care’s Patient Portal. You must have an active email address and email account that you check and monitor. If you do not have an active email account that you use and monitor, you will not be a good fit for our practice. This form is for elderly adult new patients with no access to a computer or the internet.

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Auto Claims Form

CNY Family Care will send bills to your auto insurance carrier as a courtesy to our patients. This form is required for this process to begin. Please complete this form and bring it to the office when you come for your office visit if you would like us to send the bill to your insurance carrier.

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Financial Policy Agreement (PDF)

– We require all our patients to read and attest to the terms of our Financial Policy Agreement. We require a one-time electronic signature from our patients at the time of your visit, attesting that you understand and comply with our policies.

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Notice of Privacy Practices (PDF)

This updated document describes how medical information about patients may be used and disclosed and how patients can get access to this information.

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SELF-ATTESTATION: AFFIRMATION OF QUARANTINE (PDF)

Complete this form if you or your child:

1. Have been identified as close contact to a COVID-19 positive person during their contagious period, and

2. Was not fully vaccinated at the time of exposure to a COVID-19 positive person during their contagious period, and

3. Has been in quarantine

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SELF-ATTESTATION: AFFIRMATION OF ISOLATION (PDF)

Complete if you or your child has tested positive for COVID-19 and have been in isolation. Use a separate form for each positive person. Do NOT submit to the Health Department— this form is for your use as legal documentation of your isolation and New York Paid Family Leave COVID-19 claims.

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NY State EPIC (Elderly Pharmaceutical Insurance Coverage)

  • Provides seniors 65 years of age and older on Medicare Part D with copayment assistance after any Part D deductible is met, covering many Part D excluded drugs
  • Must have Part D to apply

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