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Electronic Prescribing Information
NEW CHILD PATIENT INTAKE FORMAll 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.
NY STATE HEALTH PROXY FORMThis 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.
RETURNING ADULT PT UPDATE FORMATTENTION 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].
MEDICAL RECORDS RELEASE FORMThis form is used when a patient seeks to authorize the release of his/her medical records. Please read and follow the instructions it applies to your individual medical record needs.
WORKERS' COMP FORMThis form is needed to process all Workers' Compensation Claims.
NEW ADULT PATIENT INTAKE FORMAll 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.
NOTICE OF PRIVACY PRACTICESThis updated document describes how medical information about patients may be used and disclosed and also how patients can get access to this information.
AUTO CLAIM FORMAs 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 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.
AUTH FOR TREATMENT OF MINORSThis form needs to be completed by a parent or guardian of a minor under the age of 18 years of age. It needs to be presented to the front desk staff when a minor comes for a scheduled appointment without his/her parent.