Office Forms

Before your appointment, please print and fill out any of the necessary forms below. 

If you have questions about how to obtain records from or send records to another provider, please call our office at 585-244-9720.

To view the forms listed below, you will need Adobe Reader.

 

Administrative and New Patient Forms:

Well Visit Questionnaires:

ADD/ADHD Forms & Questionnaires:

Mental Health Forms:

COVID-19 Vaccine Forms

Patient Portal:

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good FaithEstimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For Questions or More Information
About Your Right To A
Good Faith Estimate:

visit www.cms.gov/nosurprises
or call the Elmwood Pediatric Group Billing Department at 585.244.9841.

Call us at (585) 244-9720