ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Notice to Patient:
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or
disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this
acknowledgement, if you wish.
_____________________________________________________________________________________
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.
_____________________________________________________________
Please print your name here
_____________________________________________________________
Signature
_____________________________
Date
FOR OFFICE USE ONLY
We have made every effort to obtain written acknowledgement of receipt of our Notice of Privacy from this patient but
it could not be obtained because:
The patient refused to sign.
Due to an emergency situation it was not possible to obtain an acknowledgement.
We weren’t able to communicate with the patient.
Other (Please provide specific details)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________
Employee signature
__________________________
Date
Patient Name: ______________________________________________________
For patients under the age of 18 years old, the undersigned Parent/Guardian authorizes treatment and agrees that
the policy holder will be named as the account guarantor unless noted otherwise in writing.
___________________________________
Print Name
__________________________________
Signature
___________________________________
Relationship
__________________________________
Today’s Date
TO OUR MEDICARE PATIENTS: STATEMENT OF AUTHORIZATION FOR PAYMENT OF MEDICARE BENEFITS.
I certify that the information supplied by me in applying for payment under the Title XVIII of the Social Security Act is
correct. I authorize any holder of medical information about me to release to the Social Security Administration, or its
carrier, any information about me to process my Medicare claim. I request that payment under the Medical Insurance
Program be made whether to me or Central New York Surgical Physicians PC for services rendered to me during the
period of today to life.
___________________________________________
MEDICARE BENEFICIARY SIGNATURE
__________________
DATE
ASSIGNMENT OF BENEFITS FOR ALL PATIENTS: I hereby assign all medical and/or surgical benefits, to include major
medical benefits to which I am entitled, including Medicare, Private Insurance, and any other health plan to Central New
York Surgical Physicians PC. This assignment will remain in effect until revoked by me in writing. A photocopy of this
assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges
whether or not paid by my insurance. I hereby authorize said assignee to release all information necessary to secure
payment. In the event my account is assigned for collection I agree to pay all costs of collection, including a processing
fee and any attorney fees. I affirm that the insurance information is accurate and correct. Outdated or inaccurate
information will result in charges becoming my responsibility. There will be a $20 fee for reprocessing or returned
checks.
____________________________________
Signature
__________________________________
Date
**I HEREBY STATE THAT THIS VISIT IS NOT COVERED UNDER A WORKER’S COMPENSATION OR NO FAULT CLAIM.**
____________________________________
Signature
__________________________________
Date
739 Irving Ave, St 450, Syracuse, NY 13210 (315) 470-7364
FINANCIAL POLICY/AGREEMENT
Thank you for choosing us as your health care provider. We are committed to making your treatment a success. The
following is a statement of our Financial Policy.
We will bill your health insurance carrier provided you bring in a copy of your card and our system registers eligibility
at the time of your visit. Otherwise, we will request that you pay a $100 good faith deposit and bill you for any
remaining balance. We will reimburse you if the insurance card and all necessary information needed to bill the claim
is provided to us within 24 hours of your visit. Insurance coverage varies from plan to plan.
Depending on your individual insurance coverage, your carrier may cover some, all, or none of the services rendered to you at
Central New York Surgical Physicians, P.C. Regardless of the coverage of your insurance, you are still the one responsible for the
bill. All health insurance plans represent a contract between you and your insurance company. Therefore, it is your responsibility to
see that the insurance carrier makes prompt payment and to handle any disputes or questions that may arise. I understand that:
Insurance/Medicare/Medicaid may not cover the services I receive and I am personally responsible for payment.
All co-payments for insurance plans in which we are participating providers are due prior to treatment.
Workers’ Compensation/No Fault: If your visit is related to a Comp/No Fault claim, notification MUST be made at the time your
appointment is made and/or when you check in for your initial visit. All of your necessary claim numbers along with the name,
address and telephone number of your employer and insurance carrier as well as your date of injury must be supplied at your
initial visit. Payment in full for each visit may be required until you can furnish us with all of the above listed information. We will also
need you to furnish us with your private health insurance, so please make sure that you have those cards with you at the time of your
visit.
Other ways to pay: If you do not have insurance, you will be expected to sign a self-pay form, pay a $100 good faith deposit upon
your initial visit and any additional balances thereafter as they are presented to you. We accept cash, credit cards and checks. We will
give you a copy of your billing summary for tax purposes upon request. Deductible and co-insurance balances are your financial
responsibility and must be paid promptly.
Cancelled or missed appointment: We require a minimum of 24 hours notice for canceling appointments. After two (2) missed or
no show appointments without notification to the office, you may face a penalty charge and/or dismissal from the Practice. If you cannot
make it to your appointment due to an emergency or accident, and the 24 hour timeframe has passed, please contact the office so that
we do not process you as a No Show.
Referrals: Some insurances require a referral from a Primary Care Physician (or PCP) in order to be seen at a specialist office. If
you are covered by one such insurance, it is your responsibility to obtain a referral. Failure to obtain a referral may result in
your appointment being rescheduled until such time as a referral is provided to us. If you are unsure whether your insurance
requires a referral, please contact our Billing Department and we will gladly assist you.
Insurance: You will be asked to present your current up-to-date insurance card along with picture identification at the time of your visit
every time you come. We participate in most insurance plans. If you are insured with a plan we do not do business with, payment may
be required at each visit. If you are insured by a plan we do business with but do not have an up-to-date insurance card, you will be
asked to sign a self-pay contract and payment in full for each visit may be required until you furnish us with a copy of both sides of your
insurance card. Contact your insurance company directly for any questions regarding your coverage. By signing this form you agree
that if the information you provide is incorrect, you will be responsible for payment in full. Failure to notify our office of any
insurance changes that result in incorrect billing and denial of payment by your insurance carrier will be your responsibility.
Returned Checks (NSF): You will be charged a $20.00 processing fee for any personal check returned for nonpayment.
If you have any questions regarding payment options or financial responsibilities, please contact our billing department.
I have read, understood, and agreed to the payment arrangements described in this Financial Policy/Agreement. I agree to pay any collections costs
incurred by CNY Surgical Physicians, P.C. I authorize the release of any information my insurance company may need to process my claim, and I
authorize my insurance company to issue payment directly to CNY Surgical Physicians, P.C. In the event I have personal balances owing, I will promptly
pay them and bring them current. Failure on my part to pay my personal financial obligations to CNY Surgical Physicians P.C. could result in my account
balances being turned over to collections. I agree to pay any accounting service charges assessed by the billing department on balances over 60 days.
_________________________________________
Patient’s Signature
_________________________________________
Patient’s Name
___________________________
Date
Patient Name: ________________________________________________
Part I
According to HIPAA regulations we must have your permission to speak to anyone, other than yourself, in regards to
your Personal Health Information (PHI). Please list any person(s) you would like to give consent for Central New York
Surgical Physicians to discuss your Personal Health Information with, along with their relationship to you.
______________________________________
Name
________________________________
Relationship
_____________________________________
Name
________________________________
Relationship
_____________________________________
Name
________________________________
Relationship
_____________________________________
Name
________________________________
Relationship
Part II
Due to patient confidentiality, we need your permission to leave messages regarding appointments, tests, surgery,
etc. If we cannot speak with you may we (check all that apply):
( ) Leave a message on your answering machine/voicemail
( ) Leave a message with another person designated by you
Name of person: _________________________________________________
( ) No, you may not leave any messages. You must speak with me personally.
Signed: ___________________________________________________________________
Witness: __________________________________________________________________
Date: _____________________________________________________________________
CNY Medical Center
739 Irving Avenue, Suite 450
Syracuse, NY 13210
PH: (315) 470-7364
FAX: (315) 470-7495
Brian P. Anderson, MD
Tammy J. Congelli, MD
Kenneth A. Cooper, DO
NEW PATIENT DISCLOSURE REQUIREMENTS
Providers with Central New York Surgical Physicians, P.C. are participating providers with the
following health care plans: Excellus BlueCross/BlueShield (all plans), Fidelis (all plans), POMCO (all
plans), Aetna with the exception of Syracuse Prime PPO, TotalCare, United Healthcare (all plans),
Wellcare, Tricare, Capital District Physicians Health Plan, Cigna, EmblemHealth, Independent Health,
Empire BlueCross/BlueShield, Today’s Options, AARP, HTH Worldwide, Mutiplan, Medicare, MVP (all
plans), Univera, PACE of CNY, Lifetime Benefit Solutions, Cancer Services, VA Insurance, and Humana.
We also accept No-Fault and Workers’ Compensation policies.
Jeffrey M. DeSimone, MD
Thomas S. Hartzheim, MD
Central New York Surgical Physicians, P.C. providers do not participate with the following insurances:
Medicaid (as primary insurance for new patients), Martin’s Point (may participate in the future),
Aetna Syracuse Prime PPO, Health Republic/MagnaCare, GHI Medicare, GHI HMO, NYS Department of
Health Uninsured Care Program and any out-of-state Medicaid.
Central New York Surgical Physicians, P.C. provider hospital affiliation is with Crouse Hospital,
Syracuse, New York.
A list of ancillary providers is available on our website or on paper by request.
Herbert E. Mendel, MD
Acknowledgment of Receipt:
Signature__________________________________________Date___________________
If legal representative, indicate relationship to patient_____________________________
James E. Sartori, MD
Print Name of Patient_______________________________________________________
Print Name of Legal Representative____________________________________________
William E. Schu, MD
David B. Tyler, MD
Patient Name: _______________________________________________
Date of Birth: ______________________ Today’s Date: ______________
What are you allergic to? What is the reaction?
OR
No Known Allergies _______
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
REASON FOR TODAY’S VISIT:
(
(
(
(
(
(
(
(
(
(
(
(
) Abdominal Pain
( ) Hernia – Hiatal
) Abnormal Breast Imaging
( ) Lipoma
) Appendix
( ) Lower Extremity Ulceration
) Breast Cancer
( ) Morbid Obesity
) Breast Problems
( ) Pilonidal Abscess
) Colon Cancer
( ) Post-op Check
) Cyst/Abscess
( ) Reflux/GERD
) Diverticulitis/diverticulosis
( ) Skin Lesion
) Gallbladder Problem
( ) Thyroid/Parathyroid Problems
) Hernia – Abdominal
( ) Varicose Veins
) Hernia – Inguinal
( ) Venous Insufficiency
) Other: ______________________________________________
REVIEW OF SYSTEMS: (CHECK ALL THAT APPLY)
Constitutional:
( ) Fever ( ) Night Sweats ( ) Weight Gain ( _______ lbs.) ( ) Weight Loss ( ________ lbs. )
Eyes:
( ) Dry eyes ( ) Vision change
ENMT:
( ) Frequent Nosebleeds ( ) Bleeding Gums ( ) Snoring ( ) Dry Mouth ( ) Mouth Ulcer
Cardiovascular:
( ) Chest pain on exertion ( ) Arm pain on exertion ( ) Shortness of breath when walking
( ) Shortness of breath when lying down ( ) Palpitations ( ) Known heart murmur
( ) Light-headed on standing ( ) Lower extremity swelling
Respiratory:
( ) Cough ( ) Wheezing ( ) Shortness of breath ( ) Coughing up blood ( ) Sleep apnea
Gastrointestinal:
( ) Abdominal Pain ( ) Vomiting ( ) Change in appetite ( ) Black or tarry stools ( ) Frequent diarrhea
( ) Vomiting blood ( ) GERD
Genitourinary:
( ) Frequency ( ) Urinary loss of control ( ) Difficulty urinating ( ) Increased urinary frequency
( ) Hematuria ( ) Incomplete emptying ( ) Testicular Pain ( ) Scrotal swelling ( ) Abnormal menses
( ) Vaginal Discharge
Musculoskeletal:
( ) Muscle aches ( ) Muscle weakness ( ) Arthralgias/Joint Pain ( ) Back Pain
Patient Name: _________________________________________
Date of Birth: ________________ Today’s Date: ______________
REVIEW OF SYSTEMS (CONTINUED):
Skin:
( ) Abnormal mole ( ) Rash ( ) Itching ( ) Dry Skin ( ) Growths/Lesions
Neurologic:
( ) Weakness ( ) Numbness ( ) Seizures ( ) Dizziness ( ) Frequent or severe headaches
( ) Migraines
Psych:
( ) Depression ( ) Sleep Disturbances ( ) Alcohol Abuse ( ) Anxiety
Endocrine:
( ) Fatigue ( ) Increased thirst ( ) Hair Loss ( ) Increased Hair Growth ( ) Cold Intolerance
Hematologic/Lymphatic:
( ) Swollen Glands ( ) Easy Bruising ( ) Excessive Bleeding
Allergic/Immunologic:
( ) Itching ( ) Hives
PAST MEDICAL HISTORY:
( ) Anemia
( ) Autoimmune Disease
( ) Deep Vein Thrombosis
( ) Headaches/Migraines
( ) Hyperthyroidism
( ) Liver Disease
( ) Seizures/Epilepsy
_____ NO TO ALL
( ) Anxiety Disorder
( ) Bleeding Disorder
( ) Depression
( ) Heart Disease
( ) Hypotheyroidism
( ) MRSA/VRE
( ) Sleep Apnea
(
(
(
(
(
(
(
) Arthritis
( ) Asthma
) Cancer
( ) COPD
) Diabetes – type ______
) High Cholesterol
) Kidney Disease
) Pulmonary Embolism
) Stroke
(
(
(
(
(
(
(
) Atrial Fibrillation
) Coronary Artery Disease
) Diverticulitis
) Hypertension
) Kidney Stones
) Reflux/GERD
) Other: _____________
SURGICAL HISTORY:
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
) Appendectomy
) Back Surgery
) Bariatric Surgery
) Breast Surg – Lumpectomy
) Breast Surg – Mastectomy
) Breast Surgery
) Caesarean Section
) Cancer Surgery
) Cataract Surgery
) Cholecystectomy
) Colon Surgery
) Colonoscopy
) EGD
) Heart Surgery
) Heart Catherization/Stent
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
(
(
(
(
(
(
(
(
(
(
(
(
(
) Hemorrhoidectomy
) Hernia Repair
) Hysterectomy
) Joint Replacement
) Knee Surgery
) Orthopedic Surgery
) Prostate Surgery
) Reflux Surgery
) Thyroid Surgery
) Tonsillectomy
) Tubal Ligation
) Vascular Surgery
) Vein Surgery
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Date __________
Other Surgery: _____________ Date __________
Patient Name: _______________________________________________
Date of Birth: ________________ Today’s Date: ____________________
FEMALE PATIENTS ONLY:
GYN HISTORY:
Date of your last menstrual period: _______________
Do you have a regular monthly cycle? ( ) Yes ( ) No
At what age did you have your first child (if applicable)? ___________
What age were you when you had your first period? ____________
Current Birth Control: _________________________
Age at Menopause (if applicable)? __________________
Number of Pregnancies: _________________
Hormone Replacement Therapy? ( ) Yes ( ) No
Date of your last mammogram? ______________
Have you ever breast fed? ( ) Yes ( ) No
SOCIAL HISTORY:
Tobacco Use: ( ) Yes ( ) No ( ) Former – Year Quit _______________
If answer is yes or former smoker:
Type of tobacco __________________ Years Used ___________________
Packs/Day __________________ Pack Year ___________________
Alcohol Use: ( ) Yes ( ) No ( ) Former – Year Quit _______________
PLEASE CHECK ONE: None = 0 drinks per day _____ Occasional = <1 drink per day _____
Moderate = 1-2 drinks per day _____ Heavy >2 per day ______
Caffeine Use: ( ) Yes
( ) No Type: ___________________ Amount daily: _______________
FAMILY HISTORY:
Do you have any Family History of the following?
Grandfather, Grandmother, Mother, Father, Brother, Sister, Son, Daughter - only
Diagnosis:
Relation (note Maternal or Paternal)
Age at Onset
( ) Arthritis
______________________________________________________
( ) Asthma
______________________________________________________
( ) Benign hypertension
______________________________________________________
( ) Blood coagulation disorder
______________________________________________________
( ) Cerebrovascular accident
______________________________________________________
( ) COPD
______________________________________________________
( ) Dementia
______________________________________________________
( ) Diabetes mellitus
______________________________________________________
( ) Disorder of thyroid gland
______________________________________________________
( ) Heart disease
______________________________________________________
( ) Kidney disease
______________________________________________________
( ) Malignant neoplastic disease
______________________________________________________
( ) Malignant tumor of breast
______________________________________________________
( ) Malignant tumor of colon
______________________________________________________
( ) Malignant tumor of lung
______________________________________________________
( ) Malignant tumor of prostate
______________________________________________________
( ) Obesity
______________________________________________________
( ) Substance Abuse
______________________________________________________
Central New York Surgical Physicians, P.C.
New York State Department of Health
Authorization for Access to Patient Information
Through a Health Information Exchange Organization
Patient Name
Date of Birth
Other Names Used (e.g., Maiden Name):
I request that health information regarding my care and treatment be accessed as set forth on this form. I can
choose whether or not to allow CENTRAL NEW YORK SURGICAL PHYSICIANS, P.C. to obtain access to my
medical records through the health information exchange organization called HealtheConnections. If I give
consent, my medical records from different places where I get health care can be accessed using a statewide
computer network. HealtheConnections is a not-for-profit organization that shares information about people’s
health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn
more visit HealtheConnections website at http://healtheconnections.org/ .
My information may be accessed in the event of an emergency, unless I complete this form and check box #3,
which states that I deny consent even in a medical emergency.
The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this
form does NOT allow health insurers to have access to my information for the purpose of deciding
whether to provide me with health insurance coverage or pay my medical bills.
My Consent Choice. ONE box is checked to the left of my choice.
I can fill out this form now or in the future.
I can also change my decision at any time by completing a new form.

1. I GIVE CONSENT for CENTRAL NEW YORK SURGICAL PHYSICIANS, P.C. to access ALL of my
electronic health information through HealtheConnections to provide health care services (including
emergency care).

2. I DENY CONSENT EXCEPT IN A MEDICAL EMERGENCY for CENTRAL NEW YORK SURGICAL
PHYSICIANS, P.C. to access my electronic health information through HealtheConnections.

3. I DENY CONSENT for CENTRAL NEW YORK SURGICAL PHYSICIANS, P.C. to access my
electronic health information through HealtheConnections for any purpose, even in a medical emergency.
If I want to deny consent for all Provider Organizations and Health Plans participating in HealtheConnections to
access my electronic health information through HealtheConnections, I may do so by visiting HealtheConnections
website at http://healtheconnections.org/ or calling HealtheConnections at 315.671.2241 x5.
My questions about this form have been answered and I have been provided a copy of this form.
Signature of Patient or Patient’s Legal Representative
Date
Print Name of Legal Representative (if applicable)
Relationship of Legal Representative to Patient (if applicable)
Details about the information accessed through HealtheConnections and the consent process:
1.

2.
How Your Information May be Used. Your electronic health information will be used only for the following healthcare
services:
Treatment Services. Provide you with medical treatment and related services.
Insurance Eligibility Verification. Check whether you have health insurance and what it covers.
Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of
services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in
following a plan of medical care.
Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients.
What Types of Information about You Are Included. If you give consent, the Provider Organization and/or Health Plan






listed may access ALL of your electronic health information available through HealtheConnections. This includes information
created before and after the date this form is signed. Your health records may include a history of illnesses or injuries you
have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This
information may include sensitive health conditions, including but not limited to:
Alcohol or drug use problems
Birth control and abortion (family planning)
Genetic (inherited) diseases or tests
HIV/AIDS
Mental health conditions
Sexually transmitted diseases



3.
4.
5.
6.
Where Health Information About You Comes From. Information about you comes from places that have provided you with
medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers,
the Medicaid program, and other organizations that exchange health information electronically. A complete, current list is
available from HealtheConnections. You can obtain an updated list at any time by checking HealtheConnections website
at http://healtheconnections.org/ or by calling 315.671.2241 x5.
Who May Access Information About You, If You Give Consent. Only doctors and other staff members of the
Organization(s) you have given consent to access who carry out activities permitted by this form as described above in
paragraph one.
Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain
organ procurement organizations are authorized by law to access health information without a patient’s consent for certain
public health and organ transplant purposes. These entities may access your information through HealtheConnections for
these purposes without regard to whether you give consent, deny consent or do not fill out a consent form.
Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of
your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to
information about you has done so, call the Provider Organization at: [insert Provider Organization phone]; or visit
HealtheConnections website at http://healtheconnections.org/; or call the NYS Department of Health at 518-474-4987; or
7.
8.
follow the complaint process of the federal Office for Civil Rights at the following link:
http://www.hhs.gov/ocr/privacy/hipaa/complaints/.
Re-disclosure of Information. Any organization(s) you have given consent to access health information about you may redisclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug
treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if
accompanied by the required statements regarding prohibition of re-disclosure.
Effective Period. This Consent Form will remain in effect until the day you change your consent choice or until such time as
HealtheConnections ceases operation. If HealtheConnections merges with another Qualified Entity your consent choices
9.
will remain effective with the newly merged entity.
Changing Your Consent Choice. You can change your consent choice at any time and for any Provider Organization or
Health Plan by submitting a new Consent Form with your new choice. Organizations that access your health information
through HealtheConnections while your consent is in effect may copy or include your information in their own medical
records. Even if you later decide to change your consent decision they are not required to return your information or remove it
from their records.
10. Copy of Form. You are entitled to get a copy of this Consent Form.