Churchville Chili Family Medicine
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WELCOME TO CHURCHVILLE-CHILI FAMILY MEDICINE

currently ACCEPTING NEW PATIENTS
Follow the links below to complete your new patient forms.

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

Aetna
Blue Cross Blue Shield
Cigna
Empire Plan
Excellus
Highmark WNY
Highmark Medicare WNY
Independent Health
Martin's Point
MVP
Nova
Premier Options (through Excellus)
Tricare (East) & Tricare for Life
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
New Patient Welcome Letter
File Size: 149 kb
File Type: pdf
Download File

IMPORTANT: PRACTICE POLICIES:
Practice Policies - 2023
File Size: 375 kb
File Type: pdf
Download File

NOTICE OF PRIVACY PRACTICES
NPP - 2022-2023
File Size: 202 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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