Forms & Policies
Online Resources
Patient Portal
We have a patient portal available from the home screen of our website for our patients’ use. This allows real-time access to medications, labs, and upcoming appointments. You will also be able to request appointments, request refills, and message our clinical and office staff. This web based Patient Portal is to be used for NON-URGENT issues and it will only be monitored on business days.
- To activate your portal account you will need to obtain an access code from our office.
- Parents can be listed as an authorized representative to have direct access to their child’s portal until the child reaches the age of 12. Per NYS Law on Adolescent Health Information, patients 12 years and older should be the only ones allowed full and unlimited access to their medical records. On the child’s 12th birthday the authorized representative’s access code will no longer be valid and the account will be locked out.
- A new activation code will be given directly to the patient at their next Annual Well Visit as an adolescent (12 years and older). Access codes will not be given to the adolescent patients over the phone.
Portal Activation Troubleshooting
- Your activation code is case sensitive and will need to be entered exactly as it has been provided to you.
- If you are activating the account as an authorized representative, you will need to add YOUR NAME, BIRTH DATE, AND E-MAIL ADDRESS under personal information in the activation screen, not the patient’s.
Patient Forms
You may download and print any of the forms listed below before coming to our office. You may either bring them with you to your visit or fax them to us before your appointment. To view our forms, you will need Adobe Reader. You may download Adobe Reader for free by visiting www.adobe.com.
- Information for New Patients
- Family Info and History Sheet PCMH 2024.2025
- Transfer Out of Practice Form
- Transfer INTO the Practice Form
- Vanderbilt PARENT Initial Assessment Form
- Vanderbilt TEACHER Initial Assessment Form
Practice Policies
Billing and Insurance
Many people have insurance to cover some, but not all of the cost of your medical care. Most insurance plans require a deductible, co-insurance payment, co-payment or other out of pocket expense, which must be paid by the family or patient. We rely on you to become familiar with your insurance policy and to bring your insurance card with you to each visit. We consider the individual (family member or not) accompanying the child to the office responsible for the payment at the time of service.
Our practice participates with a wide range of area and national carriers; however, there are instances when we are not contracted with your specific insurance carrier or you may not have insurance coverage. If this is the case, 100% of our fees are required to be paid at the time of service. As a courtesy to you, we will file your insurance claim for you for services received so that your insurance carrier reimburses you in a timely fashion. If you have any questions regarding your insurance coverage prior to your visit, please contact your insurance carrier’s member services for an explanation of your healthcare plan.
Many insurance companies require you to select a primary care physician (PCP) prior to being seen for care. If your healthcare plan has this requirement, please be sure you have notified them that you have selected the physician of your choice in our office. It is your responsibility to add a new baby or adopted child to your insurance policy. Insurance claims, which are denied as the result of improper PCP designation, will become your financial responsibility.
Our practice participates in network with the following insurance plans:
Aetna EPO & PPO
Cigna EPO & PPO
Excellus (Rochester)
Excellus Medicaid Managed Care and Child Health Plus
Fidelis Care NY
Fidelis Care NY Medicaid Managed Care and Child Health Plus
Highmark Blue Cross/Blue Shield of Western New York
Highmark Blue Cross/Blue Shield of Western New York Medicaid Managed Care and Child Health Plus
Independent Health (*Excludes Medicaid Managed Care and Child Health Plus)
Lifetime Benefits Solutions
Molina Medicaid Managed Care and Child Health Plus (*formerly known as Your Care or Monroe Plan)
MVP
MVP Medicaid Managed Care and Child Health Plus
NYS Medicaid (*Excludes Medicaid out of New York City and/or other states)
Out of Area Blue Cross Blue Shield plans (excludes some HMO policies)
The Empire Plan
Tricare East EPO & PPO
United Healthcare
United Healthcare Medicaid Managed Care and Child Health Plus
Univera Healthcare
**As most insurance companies offer many different plans including self-funded plans and HMO policies, we cannot guarantee that we are in-network with every single plan that each insurance company offers. It is your responsibility to contact your insurance carrier to confirm our participation in your specific health insurance plan prior to receiving services. If we are not in-network with your insurance and/or you have chosen to receive services here without confirming network status with your insurance provider, you will be responsible for payment.
Participating Physician Organizations and 3rd Party Claim Administrators:
AHP-Accountable Health Partners
Lifetime Benefit Solutions (formerly known as EBS-RMSCO)
Multiplan
PHCS
POMCO
Sheet Metal Workers
Statewide Independent PPO