Copyright 2017 Westfield Family Physicians, PC
WESTFIELD 716.326.4678 | SHERMAN 716.761.6144 | CONTACT US
Thursday July 20, 2017
For your convenience, we provide printable forms on our website. These are the most common forms we might have you fill out in the office. Just click on the title of each form to open a printable PDF version that you may print and complete before coming in for your visit.
In order to view these forms, you must have the Adobe Acrobat Reader or other PDF readers installed on your computer. You may download the latest version of Adobe Acrobat Reader here.
Depression Screener - PHQ-9
You may be asked by your healthcare provider to complete this depression screening form prior to your visit. You may give it to your nurse on the day of your visit.
Glucose Home Monitoring Log
Do you have diabetes? We want you to be engaged in your own care, so we provide this useful blood glucose log for you to print and keep track of your own blood sugar levels. Please bring your log to your routine visits with your healthcare provider so he/she can see what is happening with your blood sugars.
Blood Pressure Home Monitoring Log
Do you have high blood pressure? We encourage regular monitoring of blood pressure. Feel free to click on the log name above and print it out for your own use. Please bring your values to your routine appointments with your healthcare provider.
BILLING AND INSURANCE
Get Covered! Brochure
The Chautauqua County Health Network has a program called Get Covered! This program helps residents of Chautauqua County obtain a health plan they can afford.
Workers' Compensation Information Form
If you have had a work-related injury and have an open Workers’ Compensation case, this form should be completed before your first visit with your healthcare provider.
PCP Change Letter
We often give this letter to patients who see one physician regularly but have another physician recorded with their health plan. We encourage that you update the member services department of your health plan when you change physicians. Open the link above for a list of common health plans with which we participate and their member services phone numbers.
Do you have a complaint about any experience at Westfield Family Physicians? We want to hear about it so we can improve our processes. Just fill out this form and hand it to one of our staff, or send it to the attention of our Office Manager at the Westfield office.
Authorization to Disclose Protected Health Information (Records Release TO Us)
We are sometimes required to obtain your authorization before your records are released to our office. For example, if you decide to transfer your care from another office, you will be required to fill this form out so your health records can be sent to our office.
Authorization to Disclose Protected Health Information (Records Release FROM Us)
We are sometimes required to obtain your authorization before your records are released from our office. For example, if you decide to transfer your care to another office, you will be required to fill this form out so your health records can be sent to that other office.
Notice of Privacy Practices
This Notice describes how medical information about you may be used and disclosed, and how you can access this information.
Glossary of Medical and Insurance Terms
We are providing this glossary to help you make sense of the healthcare industry so that you know better how health insurance works, what you are financially responsible for with respect to your care, and how you can be a more informed healthcare consumer.
Adult Preventive Visit Forms
Please complete these forms and bring them with you to your preventive visit if you are instructed to do so by our staff.
Medicare Health Risk Assessment
We have unique preventive visits for Medicare beneficiaries. If you are a patient and you are already established at our office, please complete this form prior to your preventive visit and bring them with you that day.