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Patient Forms

Forms & Policies

Before your appointment with us, quickly and conveniently access patient forms from our practice.

Secure Online Forms

To view the forms listed below, you will need Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.

New Patient Forms

Pregnancy Forms

Patient Rights & Responsibilites

Our patients have the right to:

  • Receive care and treatment without regard to age, race, color, sexual orientation, religion, marital status or national origin;
  • Receive information about our provider’s professional credentials, business hours of operation, practice locations and services provided, including how to access after hours care in the event of an emergency;
  • Receive quality health care in a considerate, courteous and respectful manner;
  • Be treated with respect and recognition of her dignity and right to privacy;
  • Obtain complete, current information concerning a diagnosis, treatment and prognosis from a provider in terms that she can reasonably be expected to understand;
  • Receive all information needed to give informed consent for any procedure or treatment;
  • Participate in decision-making with her provider about her health care;
  • Refuse treatment as allowed by law, and be informed by her provider of the medical consequences;
  • Have access to her medical records as permitted by New York State law;
  • Retain the confidentiality of medical records and information, with the authority to approve or refuse the Practice’s disclosure of such information, to the extent protected by the law;
  • Express any concerns about the care and services provided by a provider or any other staff member, and have the Practice investigate and respond to these concerns without fear of reprisal;
  • Make recommendations regarding the Practice’s patient rights and responsibilities.

Our patients have the responsibility to:

  • Be an active partner in the effort to promote and restore health by:
    • Openly sharing information about her symptoms and health history with her provider;
    • Listening;
    • Asking questions;
    • Becoming informed about her diagnosis, recommended treatment and anticipated possible outcomes;
    • Following the plans of care she has agreed to (such as taking medications and making and keeping future appointments);
    • Returning for further care, if any problem fails to improve; and
    • Accepting responsibility for the outcomes of her decisions.
  • Participate in understanding her health problems and developing mutually agreed upon treatment goals;
  • Inform her provider in any changes in health status;
  • Assure her current address and phone numbers are provided to the office;
  • Share with the provider any concerns about the medical care or services she receives;
  • Respect the time set aside for her appointments with the providers and give as much notice as possible when an appointment must be rescheduled or cancelled;
  • Understand that emergencies arise for her providers and that her appointment may be unavoidably delayed or rescheduled as a result;
  • Respect all providers and staff members;
  • Follow the instructions and guidelines given by her provider;
  • Show her insurance card and pay any co-payments or visit fees to the provider at the time the service is rendered;
  • Become informed about her insurance policy and coverage guidelines;
  • Become informed about Genesee Valley OB/GYN financial policy and administrative office procedures and abide by them.