Patient Forms
Before your appointment with us, quickly and conveniently access patient forms from our practice.
Download Patient Forms
To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com. Please bring your completed forms with you to our office at the time of your visit.
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In order to have a patient portal account you will need to already be a patient at this practice. To activate your account, you will need to receive an activation code from us. Once you have received the code, you will be able to create your own username, password, and other login information used to verify your identity. If you would like to activate your portal account, please contact our office to receive your activation code.
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Download General Information document
HIPAA
Privacy Practices: This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.
We are required by law to maintain the privacy of you protected health information, to notify you of our legal duties and privacy practices with respect to you health information, and to notify affected individuals following a breach of unsecured health information. This notice summaries our duties and your rights concerning your information set forth more fully in 45CFR Part 164.
Use and Disclosures we may without written authorization.
We may use and disclose your health information for certain purpose without your written authorization, including the following:
Treatment: We may use and disclose your information for the purpose of treating you. We may disclose your information to another healthcare provider so that they may treat you; appointment reminders; or to provide information about treatment alternatives or services we offer.
Payment: We may use or disclose your information to obtain payment for services provided to you.
Healthcare Operations: We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, training of our employees.
Other Uses and Disclosures: We may use and disclose your information for certain other applicable laws/regulations, including: To avoid a serious threat to your health or safety of others.
As, required by state or federal laws such as reporting abuse, neglect or certain other events.
Workers compensation laws or certain public health activities such as reporting certain diseases.
For certain public health oversight activities such as audits; investigations, or licensure actions. In response to a court order, warrant or subpoena in judicial or administrative proceedings.
For research purpose if certain request conditions are satisfied.
In response to certain request by law enforcement to locate a fugitive, victim, or witness, or to report death or certain crimes.
To coroners, funeral directors, or organ procurement organizations.
Disclosures we may Make Unless you Object: We may disclose your information described below.:
To a member of your family, relative, friend or other persons who is involved in you healthcare (added to your communication consent or payment for your healthcare. We will limit the disclosure to the information relevant to that person's involvement in your healthcare or payment.
To maintain our facility directory. If a person asks for you by name, we will only disclose your name, general condition, and location in our facility. We may also disclose your religious affiliation to clergy.
Use and Disclosures with Your Written Authorization: Other uses and disclosures not described in this notice will be made only with your written authorization, including most uses and disclosures of psychotherapy notes; for most marketing purpose; or if we seek to sell your information.
You may revoke your authorization by submitting a written notice to the Privacy Contact Identified below.
The revocation will not be effective to the extent we have already taken action in reliance on the authorization.
You're Rights Concerning Your Protected Health Information: You have the following rights concerning your Health Information. To exercise any of these rights, you must submit a written request to the Privacy Officer Identified below.
You may request additional restrictions on the use or disclosures of information for treatment, payment, or healthcare operations. We are NOT required to agree to the request restrictions except in the limited situation in which you or someone on your behalf pays for an item, or service, and your request that information not be disclosed to a health insured.
We normally contact you by telephone or mail at your home address. You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable request.
You may inspect and obtain a copy of records that are used to make decisions about your care or payment for your care, including and electronic copy. We may charge you a reasonable cost-based fee for providing the records. You may request that your protected health information be amended. We may deny your request for a certain reasons, e.g., if we did not create the record or we determined that the record is accurate and complete.
You may receive an accounting of certain disclosures we have made of your protected health information.
You may obtain a paper copy of the Notice. You have this right even if you have agreed to receive the Notice electronically.
Changes to the Notice: We reserve the right to change the terms of this Notice at any time, and to make the new Notice effective for all protected health information that we maintain. If we change our privacy practices, we will post a copy of the current Notice in our reception area and on our website. You may obtain a copy of the Notice from our receptionist or Privacy Officer.
Complaints: You may complain to us or to the Secretary of Health and Human Services, if you believe your privacy rights have been violated. You may file a complaint in writing with us by notifying our Privacy Officer. We will not retaliate against you for the complaint.
Contact Information: If you have any questions about this Notice, or if you want to object to or complain about any use or disclosure or exercise any right as explained above, please contact:
Privacy Officer: Kathy Corbett
Phone: 315-492-5915 Ext. 8
Address: 4850 Broad Road, Suite 2C, Syracuse, New York 13215
Email: kathyc@advancedob-gyn.com
Effective date: This Notice is effective November 1, 2005
