Phone (518) 357-2011
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ACO Newsletter and Opt out Form (0ver 65)Five Corners Family Practice is participating in a Medicare Shared Savings Program Accountable Care Organization. If you are 65 years of age and older and are Medicare Primary Insurance, please take a look at the attached information and "Opt Out" Form.
New Patient Demographic FormAll patients entering our office are required to complete the attached form. If able, print off, complete and bring it in with you for your first appointment. If you are not able, simply come to the office at least 30 minutes prior to your scheduled appointment so we are able to have you complete all forms prior to your appointment.
Pediatric Patient History QuestionnairePrint out and complete the pediatric health questionnaire that is required for all patients under the age of 16 as a new patient within our office. Hand it to the receptionist upon your arrival for your new patient appointment.
Authorization to release health informationIf you need to transfer your medical records to a new physician, or have them transferred to us,print out and complete the HIPPA Compliant Release of Medical Records Form. You can send it to your previous physician or to us depending on your needs.
Authorization to release records to patient onlyIn addition to the NYS, federal approved authorization release, you will need to complete this form and submit it to our office if you are requesting our records as they pertain to you.
Adult History Questionnaire(new Patients)Print out and complete your patient history form required at your first visit within our office. Easy to use and gives you the time you need to do in your home instead of in our office. Hand to the receptionist when you arrive.
Adult Annual History QuestionaireExisting Patients will need to complete and submit this update annually. Simply print, complete and bring with you to your appointment or submit through the patient portal.
New Patient Welcome LetterOur office welcome letter offers informational communications that allow you to use as a reference. Please print to keep available for quick telephone numbers and information on how to reach us when you need us! Thank You
Medicare Health Risk Assessment FormMedicare requires you complete a Health Risk Assessment Form at your annual wellness visit. This form is 3 pages in length and located on our website. Easy to print, complete at home and bring it in at your scheduled physical appointment. If you are not able, please arrive 15 minutes earlier then your appointment time to complete in our office. Thanks!!
Patient Portal Instructions