Welcome to Offifce of Dr. Everett Forman, PC

 Dr. Everett Forman, P.C.

You Have the Right to:

1. Be treated with dignity and respect for both your person and property.
2. Be free from all forms of abuse, including verbal, mental, sexual, and physical mistreatment, neglect, exploitation, or misappropriation of property.
3. Voice concerns or complaints about your care without fear of retaliation, and have those      concerns addressed in a timely manner (see "Complaints and Suggestions" section).
4. Actively participate in decisions regarding your medical treatment, including the      right to:
   • Participate in your care planning;
   • Be informed about your diagnosis, treatment options, risks, and expected outcomes;
   • Consent to or refuse any part of the care or treatment plan;
   • Be notified in advance about any changes to your care.

1. Receive services consistent with the plan of care established with your provider.
2. Have your health information handled confidentially in accordance with HIPAA. A copy of our Notice of Privacy Practices is provided separately and details how your      information may be used or disclosed.
3. Be informed, before care is initiated, of any expected out-of-pocket costs, whether      services are covered by insurance or Medicare/Medicaid, any changes to      this information as they occur
4. Receive written notice in advance if any service may not be covered or if there is a      change in your ongoing care.
5. Contact the New York State Department of Health for any unresolved complaints or concerns  about your care (contact information below).
6. Access  information about supportive services in the community including advocacy      and aging resources.
7. Be protected  from any form of discrimination or retaliation related to the exercise of      your patient rights.
8. Request and  receive auxiliary aids, language interpretation, and services for visual      or hearing impairments.
9. 
   

Complaints and Suggestions

1. We encourage you to bring any concerns to the attention of our staff or your physician directly.
2. You may also  submit a written complaint to:

Dr. Everett Forman, P.C.
Attn: Practice Administrator
585 Troy-Schenectady Road
Latham, NY 12110

1. Phone complaints      can be made during business hours (Monday through Friday, 11:00 AM – 5:00      PM) by calling: 518-785-6004
2. If we are unable      to resolve your concern, you may also contact the:
       New York State Department of Health - Complaint Hotline: 1-800-663-6114

Effective Date: June 3, 2025
Dr. Everett Forman, P.C.

This Notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Commitment to Your Privacy

At Dr. Everett Forman, P.C., we are committed to protecting the privacy of your health information. We are required by law to:

• Maintain the  privacy of health information that identifies you.
• Provide you with this Notice of our legal duties and privacy practices.
• Abide by the  terms of this Notice currently in effect.

Who Will Follow This Notice

This Notice applies to all employees, staff, health care professionals, and contractors affiliated with Dr. Everett Forman, P.C. who are authorized to access or use your medical records for treatment, payment, or healthcare operations.

How We May Use and Disclose Your Medical Information

We may use or disclose your health information for the following purposes without your specific authorization:

1. Treatment

We may share your health information to provide or coordinate your care. For example, if you see a specialist or require lab testing, we may disclose relevant medical information to those involved in your treatment.

2. Payment

We may use and share your health information to obtain payment from your insurance provider or other entities responsible for payment.

3. Health Care Operations

We may use your information for office administration, staff training, and quality assurance purposes to ensure you receive high-quality care.

4. Appointment Reminders

We may contact you to remind you of appointments by phone, voicemail, text, or email.

5. Treatment Alternatives and Health-Related Benefits

We may inform you about treatment options or health-related services that may benefit you.

6. Individuals Involved in Your Care

If you do not object, we may disclose relevant information to family members, friends, or caregivers involved in your treatment or payment.

7. Business Associates

Third-party service providers (e.g., billing companies, IT consultants) may access your information when contracted to assist with operations. They are legally required to safeguard your information.

Special Situations

We may also disclose your information in the following circumstances:

• As Required by Law
• Public Health Reporting
• Victims of Abuse or Neglect
• Health Oversight Activities
• Lawsuits and Disputes
• Law Enforcement Requests
• To Avert a  Serious Threat to Health or Safety
• Organ and Tissue  Donation
• Medical Examiners and Funeral Directors
• Correctional Institutions (if incarcerated)
• Military,  National Security, and Presidential Protection Services
• Authorized  Emergency Relief Efforts (e.g., disasters)

Electronic Medical Records

Your information may be stored and accessed electronically. We utilize secure electronic health record systems for clinical, billing, and administrative purposes. Access is granted only to authorized individuals.

Your Rights Regarding Your Medical Information

You have the following rights regarding your health information:

1. Right to Inspect and Copy

You may review or request a copy of your medical and billing records. Requests must be submitted in writing to our office. We may charge a nominal fee for copies.

2. Right to Amend

You may request corrections to your records if you believe they are inaccurate. Submit your request in writing with a reason for the amendment.

3. Right to an Accounting of Disclosures

You may request a list of certain disclosures we’ve made, excluding those for treatment, payment, and healthcare operations.

4. Right to Request Restrictions

You may request limits on how we use or share your information for treatment, payment, or operations. We are not required to agree, but we will comply with restrictions you request regarding out-of-pocket payments.

5. Right to Confidential Communications

You may request to be contacted in specific ways or at specific locations (e.g., your work address instead of home).

6. Right to Breach Notification

You will be notified of any breach of your unsecured protected health information as required by law.

7. Right to a Paper Copy of This Notice

You may request a paper copy of this Notice at any time.

Changes to This Notice

We reserve the right to revise this Notice. Any changes will apply to medical information we already hold and to new information we receive. Updated versions will be posted in our office and available upon request.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with:

Privacy Officer
Dr. Everett Forman, P.C.
585 Troy-Schenectady Road
Latham, NY 12110
Phone: 518-785-6004

You may also file a complaint with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. To file a complaint with the U.S. Department of Health and Human Services, contact:
Office for Civil Rights (OCR)
Website: https://www.hhs.gov/ocr/privacy/hipaa/complaints/
Phone: 1-800-368-1019

Other Uses of Health Information

Any uses or disclosures not covered by this Notice or the laws that apply to us will require your written authorization. You may revoke your authorization at any time in writing.

Questions? If you have questions or concerns regarding this Notice or your rights, please contact our office at:
Phone: 518-785-6004

 

What is considered a "No-Show" or "Late Cancellation"?

Dr. Everett Forman, P.C. defines a no-show or late cancellation as any scheduled appointment where the patient:

• Does not arrive for the appointment
• Cancels or reschedules with less than 24 hours’ notice
• Arrives more than 30 minutes late and cannot be accommodated

Missed appointments disrupt medical care and impact the availability of services for other patients. When a patient does not show up for a scheduled visit, it delays care for them and prevents another patient from being seen.

How to Avoid a No-Show Fee
To help us provide timely care to all patients, we ask that you:

• Please Confirm your appointment. We will attempt to contact you several business      days before your appointment to confirm. If we cannot reach you, we may leave a voicemail reminder.
• Please Arrive 5–10 minutes early. This ensures time to verify insurance, answer billing questions, and complete any necessary forms prior to your visit.
• Please Provide at least 24 hours’ notice for cancellations. If you need to      cancel or reschedule, please notify us at least 24 hours in advance to avoid a $50 no-show fee. This helps us reallocate that appointment to another patient who may be waiting for care.

We understand that emergencies can arise. If you are unable to provide 24 hours’ notice, please call us as soon as possible to explain the situation. TEL: 518-785-6004.

Consequences of Missed Appointments

• A $25 no-show fee may be charged for missed appointments without proper notice. This fee is not billable to insurance and must be paid prior to your next visit.
• Three or more missed appointments within a 6-month period may result in dismissal from      the practice. If dismissed, you will be notified in writing, and all      future scheduled visits will be canceled. Only emergency or urgent care may be provided during the 30-day transition period following dismissal, as required by law.

By signing below, you acknowledge that you have read, understood, and agree to the no-show and cancellation policy as outlined above.

Patient Signature: _______________________________      Date: _______________
 

Patient Parent/Representative/Guardian (if applicable)________________________
 

Practice Representative (if applicable): __________________________