FORMER PATIENTS LOOKING TO RETURN TO CNY FAMILY CARE
Patients that CNY Family Care has discharged, or patients who have transferred care to another primary care physician, are not able to re-establish with our practice without extenuating circumstances. If a former patient feels they have an extenuating circumstance, they may submit a written request to the practice requesting reinstatement. For patients ages 18 and older, the patient (not a parent/spouse/relative) must submit a request to the practice requesting reinstatement. Pertinent information regarding the reason for reinstatement must be explained. All reinstatement forms submitted to our practice are reviewed. Verbal requests, requests from someone other than the adult patient, or from a patient representative (unless a patient is unable to represent themselves for physical or mental reasons) will not be considered.
Name of Person Submitting Form
First Name
Last Name
Relationship to Patient
Self/Patient
Parent of Patient under 18
Legal Guardian of Patient
Other
Name of PATIENT Who Is Requesting Reestablishment
First Name
Last Name
If the patient is not the one submitting this form, please document why they are unable to make the request themself:
Patient's Date of Birth
-
Month
-
Day
Year
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email Address
example@example.com
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Insurance Carrier
Subscriber ID #
Primary Ins
Secondary Insurance Carrier (if applicable)
Subscriber ID #
Secondary Ins
Please use the field provided below to explain your extenuating circumstance related to your previous discharge or transfer of care from our practice. You must explain why you wish to be reinstated.
Signature of Patient/Patient Representative
Date
-
Month
-
Day
Year
Date
Relationship to Patient
Self/Patient
Parent of Patient under 18
Legal Guardian of Patient
Other
If you have been discharged due to non-payment, discharged due to non-compliance with medical advice, discharged due to excessive no shows or cancellations, or discharged due to inappropriate behavior in the practice, it is unlikely you will be reinstated. If this request to reestablish with CNY Family Care is declined, a letter will be mailed to communicate this decision. If the decision is made to reinstate you, you must follow all steps of our new patient process including agreeing to activate and utilize our patient portal.
Submit
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