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Patient Information


HIPAA PRIVACY POLICY: Health Insurance Portability & Accountability Act.


ALL PATIENTS:  Please bring the following with you to each appointment:

  • Driver’s License/Photo ID
  • Current Insurance Card
  • Medicine bottles for all current prescriptions; a list of refills needed and a list of over the counter medications to include dose and frequency
  • Copies of any recent test results and any medical reports that belong with these results
  • Information about your medical and/or surgical history
  • Any insurance forms that would need to be completed
  • Any questions you may have for the doctor/provider


  • Please arrive 15 minutes prior to your scheduled appointment so we can update your demographic and insurance information.


  • Please arrive 30 minutes prior to your scheduled appointment time.
  • Please complete the patient information and medical history forms prior to your visit. This may be done in one of three ways:
    1. Patient information can be done through the CNY Family Care Portal also.
    2. When you call to make your appointment, our team member can send out a packet of forms to your home for you to complete at your convenience. Please be sure to bring them with you for your first scheduled appointment.
    3. The needed new patient forms can be found on our website: the time of your FIRST visit, we ask that you come prepared to present a photo ID that will verify your name and home address.


  • If your insurance plan requires you to pay a co-payment, co-insurance, and/or a deductible, you will be expected to pay this when you CHECK IN in for your scheduled office visit.
  • Payment will also be required for all non-covered services.
  • For your convenience, we accept CASH, CHECK, Visa, Master Card, Discover and American Express credit cards. Established patients can also make credit card payment via our “Portal” in Medent or on this website = see Bill Pay Tab at top of page.
  • If you are a self-pay patient, CNY Family Care will offer you a 15% discount off of the total cost of services to be paid in full at the time of service. [See NEW 2017 Financial Policy].


  • We understand that there are times when things come up and patients may be unable to keep their scheduled appointment time or are going to be delayed. We ask that you please call our office to let us know if this is going to happen.
  • As a courtesy we request that you provide us with 24 hour notice for any appointment cancellations.


CNY Family Care offers completion of forms as an added service to patients.  It is our policy to collect a fee for these forms since it does require staff time and supplies to complete them accurately.
The steps include the following:
  1. Someone must receive the form and review it.
  2. Someone then reviews the medical record to obtain physician notes and any other information required.
  3. The information must be filled out on the specific form presented.
  4. Office notes must frequently be copied to accompany the form.
  5. Physicians must review and sign for the information presented on the form.
  6. There must be documentation made into the patient record that the forms were received, completed and returned.
  7. The form is made available on the Patient portal or is prepared for the patient to pick up. 
  8. The form must be scanned and entered into electronic medical record.
CNY Family Care charges for the following forms.
  • Family Medical Leave (FMLA) Forms: $20
  • Paid Family Leave (PFL) Forms: $20
  • Disability (DBL) Forms employer or personal: $20
  • Adoption or Foster Care Forms: $20
  • DMV: Disability Form and Driver Exam Report $20
  • Life insurance forms $20
  • Paperwork for patient assistance programs $20
If more than one of the forms is presented at the same time, the charge will be $10 for each additional form. From time to time other forms may be added to this list.
The process is as follows:
  1. Patient comes to the office with form, or form is received electronically by CNY Family Care. 
  2. The patient is provided with CNY Family Care’s policy on completing forms.
  3. The patient agrees to the charges and pays the appropriate amount to the receptionist / business office staff member.
  4. The Form is delivered to the nursing team for review and completion by the physician.
  5. The Form is completed by the team. 
  6. Once the form is completed a portal message is generated to the patient or a phone call is made to the patient indicating that the form is complete and available.

CNY Family Care is pleased you have chosen our practice for your medical care. Please read our financial policies below. New patients to the practice must present at least one source of a valid picture ID. We do ask patients to allow us to take a photograph of them so that we can do the utmost to protect their identity and insurance benefits on future visits.
Self-pay Patients
  • You will be required to sign an acknowledgement of self-pay status at each visit when you request to be self-pay. This is a contract between you and CNY Family Care, LLP where you accept full responsibility for the costs of your office visit at each date of service.
  • Payment for services provided in the physician office requires a $100.00 deposit at the time of check in. You will then be required to pay the remainder of your bill at check out (after you have seen a provider) based on the services that were provided to you that same day.
  • If your balance is excessive, you MUST speak with a billing representative to make payment arrangements BEFORE you leave our offices.
  • For your convenience, we accept cash, check and credit card payments.
  • We offer a 15% discount on all services paid in full at the time of service.
  • A receipt will be given to all patients who have made a payment.

Patients with insurance

  • Please bring your insurance card to each visit so that our office staff can verify eligibility.
  • Patients who do not have their insurance card at the time of the visit will be billed directly. (unless insurance can be verified for payment on the date of service).
  • If your insurance carrier does not respond within 60 days, the balance will become your responsibility.


  • Co-payments will be collected at the time of service. We accept cash, checks, Master Card, Visa, Discover and American Express. Please make every effort to pay your co-payment at your appointment. Our practice has contractually agreed with your insurance company to collect co-pays at the time of your visit.

Workers Compensation

  • Please inform the registration department that your visit is due to a work-related injury.
  • If this is a first visit, you MUST bring a copy of the injury report filed with your employer, your employer’s address and phone number, the supervisor’s name, and your employer’s compensation carrier, address, and phone number.

Auto Accident Visits/Liability

  • Please inform the registration department that your visit is due to an auto related accident.
  • Please give us all of your insurance carrier’s information, the name, address and phone number.
  • We will bill your auto carrier as a courtesy, but it is ultimately your responsibility to make sure that your bill is paid.
  • We will bill you if payment is not received from your auto insurance carrier.
Billing Questions
  • We realize that special circumstances may arise and will assist you in every way we can.
  • Please understand we reserve the right to report delinquent accounts to the credit bureau after all efforts have been exhausted to obtain payment.
  • There is a $20 returned check fee due and payable from you for each check payment that is returned by your bank.
  • Accounts that are delinquent for more than 60 days and have not made payment arrangements with the practice are subject to interest charges of 1.5% per month.
  • Please feel free to contact our billing office with any questions at (315) 463-1600 option 2 from 8 AM to 5 PM Monday thru Friday. If we are not available, please leave a message.
Evening and Weekend hours
  • We charge a $15.00 charge for after hour appointments.  This is for appointments from 5:00 PM to 9:00 PM and on all day Saturday and Sunday. If your insurance does not cover this, you will be responsible for this charge.


CNY Family Care tries very hard to work with all types of patients and their families. There are times we are faced with discharging a patient. The following are some reasons why you may be discharged:

  • If you call and make a new patient appointment and no show 2 times you will not be allowed in our practice.
  • If you no show (without cancellations) more than 3 times you may be discharged
  • If you treat our staff inappropriately (yelling, swearing, name calling, etc.) you may be discharged.
  • If you have a balance that is more than 90 days overdue after your insurance has paid, and you have not set up repeating payments, you may be discharged.
  • • If you fail to comply with your physician’s recommendations for continuous follow up for continuity of care you may be discharged for non-compliance.


Immunizations are the single most important medical measure that a parent can do to keep their child healthy. CNY Family Care adheres strictly to the immunization guidelines of the American Academy of  Family Practice and the Advisory Committee on Immunization Practices for the Centers for Disease Control.  Click here to visit the website.  We DO NOT alter the immunization schedule based on individual requests. Multiple studies support the safety and effectiveness of vaccines in preventing disease and death. Protecting children from vaccine-preventable illness is one of the most important things we can do to insure that your child lives a long and healthy life. Because we care about your children, we require our patients to adhere to the minimum required vaccines for school attendance in New York State.  Click here for the USA Today report on the latest study showing that there is not a link between childhood vaccines and autism.

Notice to Parents of minor children:  ALL children under the age of 17 must have a parent (or legal guardian) with them to sign paperwork that is required to receive any immunization(s). 

As of 2015 in New York State, the following vaccines are required

  • DTaP
  • (diphtheria, tetanus, and pertussis)
  • IPV (polio)
  • Meningococcal
  • MMR (Measles, mumps, rubella)
  • Hepatitis B, Varicella (chickenpox)
  • HIB (hemophilus Influenza type b)
  • Prevnar (pneumococcus)

The following vaccines, while highly recommended, are not required by New York State for children to begin attending school:

  • Hepatitis A, HPV (Human Papilloma Virus)
  • Annual Influenza vaccines.


At CNY Family Care, LLP we make every effort to cooperate with your managed care programs and their policies regarding referrals and pre-certification. We do this because we understand the benefits of HMO programs and the decreased costs to our patients because of HMO availability. However, one of the requirements of HMOs is to make referrals to specialists and to pre-certify various procedures and hospitalizations. We have agreed to follow these type of guidelines in order to participate with your insurance program. Please assist us in cooperating with your HMO or PPO program.


In some instances our providers may refer a patient to a specialist outside our office for a consultation or testing. Please be sure to keep these appointments and contact us if you have to cancel or change any appointments. Within our office, all referrals are kept open and monitored until the corresponding result or consultation note has been provided to us. We track these to make sure each patient gets the needed care that was recommended by our providers. In addition, we make the necessary insurance provisions for each referral to make sure that your insurance company is aware that we have ordered these tests. This way your insurance coverage can be maximized. Some insurance companies may not pay for a referral to a specialist unless the referral is done by the Primary Care Physician.

  • As a general rule, our practice will not make referrals to specialists if a patient has not been seen in our office for the specific problem related to the referral. IF YOU ARE A NEW PATIENT, you must first establish (be seen) in our office before we will make an out of office referral.
  • Self-referrals (going to a specialist without being referred by your PCP) are typically not covered by manage care plans. If you self-refer, insurance companies will not allow us to “back date” a referral. We will not attempt to obtain a referral after the visit has occurred.
  • If you call our office for a referral, you will (unless it is for an ongoing chronic issue) be required to come in and be seen by one of our providers.
  • If you have been told that you will be contacted to schedule an appointment for testing, or to see a specialist and it has been more than a week, please follow up with our office.


A CNY Family Care, LLP we have a team of employees who work with patients to get medical records transferred into our group or out of our group to other providers. To begin this process, a patient needs to sign an authorization form and mail or fax it to our Medical Records Department. Medical release forms can be obtained in our office, or in the “FORMS” area of our website. In some circumstances, in accordance with New York State guidelines, a per-page fee may be assessed for some record transfers.


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.