Churchville Chili Family Medicine
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WELCOME TO CHURCHVILLE-CHILI FAMILY MEDICINE

NOW ACCEPTING NEW PATIENTS FOR APPOINTMENTS FROM 2.1.22
Follow the links below to complete your new patient forms.

ADULT Patient
PEDIATRIC Patient
 Accepting New Patients with the following Health Insurance: 


Aetna
Cigna
Excellus
Independent Health
Martin's Point
MVP
Nova

Premier Options (through Excellus)
Tricare (North Region)

UMR
Univera
​




Please call our office to schedule your first appointment and then
​notify your health insurance carrier of your new primary care provider.
PLEASE NOTE : our providers set aside 30 minutes for new patient appointments and typically
do not perform the annual preventive physical exam at the initial visit. 
 
​
WELCOME / INTRODUCTION
2021 New Patient Welcome Letter
File Size: 171 kb
File Type: pdf
Download File

IMPORTANT: PRACTICE POLICIES:
PPP 2022
File Size: 358 kb
File Type: pdf
Download File

NOTICE OF PRIVACY PRACTICES
2021-22 Notice of Privacy Practices
File Size: 52 kb
File Type: pdf
Download File

RECORDS RELEASE FORM :
RECORDS RELEASE FORM
File Size: 57 kb
File Type: pdf
Download File

Please complete for Separated | Divorced Parents of Pediatric Patients
File Size: 56 kb
File Type: pdf
Download File


CHURCHVILLE CHILI FAMILY MEDICINE

To provide cheerful, compassionate, competent healthcare so as to openly glorify God
Tel (585) 594-5995 - 4201 Buffalo Road, Suite 1 - P.O. Box 505, North Chili, NY 14514
(our secure fax line is reserved for medical purposes only  - no solicitation)
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