Patient Intake Appointment

Primary

Secondary

Please list individuals with whom we share your health information including diagnosis. treatment and other health care infonnation irrcluding payment. (lt is not necessary to list your primary care physician)

• Hours 8AM - 5PM, Mon, Tue, Thr, Fri. Closed Wednesday, with some exceptions.
• Daytime phone: (315) 478-2339 or (315) 478-0502, Fax: (315) 478-0439
• A physicians is always on call and may be reached on beeper at (315) 249-2684.
• Allergy Injections are given Monday, Tuesday and Thursday from 8:00-4:15PM. You must be signed in 4:15PM or you will be asked to return.
• A minor less than 18 years old must be accompanied by a Parent, or parent should complete "Designation to permit another person to consent for Health Care". We can provide you the form upon request.
• We strongly advise that you keep your follow up appointments. Patients who do not cooperate with us should not expect optimal results
• We ask that you notify us of any prescription refills you need at the time of your visit. Patients who do not keep appointments may be asked to schedule one before a prescription is refilled.
• A patient not seen within 6 months may be asked to schedule an appointment before any forms including school forms are processed.

• We participate in the following plans: AETNA, EXCELLUS BC/BS, CDPHP, FIDELIS, MEDICARE, MVP, POMCO, RMSCO, TOTAL CARE, UNITED HEALTH CARE (expect CHP/Medicaid), CIGNA, HUMANA, MULTIPLAN/PHCS, as well as several smaller plans. If you do not see your insurance carrier listed, please contact them to inquire about our participation. This listing may change without notice. Please note that our relationship is with you and not with the Insurance Company.
• We do not participate in Medicaid FFS (Fee for Service). If you have Medicaid FFS as a secondary insurance and your primary insurance does not fully cover the fees, you will be held responsible for the balance.
• It is always the patient's responsibility to make sure that necessary referrals are in place and insurance information is correct and up to date. If it is not, or we cannot verify such information, we reserve the right to reschedule the appointment or you may be held responsible for payment.
• All co-pays are due at the time of service. If you have not met your deductible, payment in full is due at time of service.
• If you have no insurance or we cannot verify insurance, full payment is due at the time of the visit.
• Patients with balances may be asked to reschedule non-urgent visits until payment has been made.
• We ask for the courtesy of 24 hours notice to cancel a scheduled appointment.We reserve the right to charge a $30 fee for patients who fail to give 24 hour notice. This charge is not covered by insurance.
• If you are experiencing financial hardship, please contact us. We will be happy to discuss a payment plan with you.
• Please allow 3 business days to process prescriptions.
• Please allow 10 business days to copy records.
• We reserve the right to discontinue our professional relationship with you if our policies are not followed.

I have reviewed and understand the above and acknowledge receipt of the "Notice of Privacy Practices" booklet. This notice is also available at our wesbite.

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