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Office Update Form

The information collected in this form will be used in our call center for physician referrals. Members of Catholic Health Medical Partners will also be listed in our online physician directory.

If you have any questions, suggestions, or problems filling out this form, please contact us.

Required fields are listed in bold.

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Member of Catholic Medical Partners (CMP):	YesNo
Would you like information about joining CMP?	Yes, please contact meNo
First Name:
Middle Initial:
Last Name:
Title (MD, DO, etc.):
Primary Hospital:
Secondary Hospital:
Are you accepting new patients?	YesNo
Specialty:
Secondary Specialty:
Clinical Interest:
Board Certified In:
Board Admissible In:
Date of Birth:
Sex:	MaleFemale
Languages Spoken:
Are you accepting children?	YesNo
Are you accepting Canadian patients?	YesNo
Privileges at Kenmore Mercy Hospital:	ActiveAssociateCourtesyConsultantOther
Privileges at Mercy Hospital of Buffalo:	ActiveAssociateCourtesyConsultantOther
Privileges at St. Joseph Campus:	ActiveAssociateCourtesyConsultantOther
Privileges at Sisters of Charity Hospital:	ActiveAssociateCourtesyConsultantOther
Privileges at Kaleida Health System:	ActiveAssociateCourtesyConsultantOther
Privileges at Erie County Medical Center:	ActiveAssociateCourtesyConsultantOther
Privileges at BryLin Hospital:	ActiveAssociateCourtesyConsultantOther
Privileges at Niagara Falls Memorial Hospital:	ActiveAssociateCourtesyConsultantOther
Privileges at Mount St. Mary's:	ActiveAssociateCourtesyConsultantOther
Methods of payment NOT accepted (check all that apply):	AetnaIHA Encompass 65 Blue ChoiceIHA Medisource BC/BS of WNYMagnaCare Blue Cross GMMailhandlers Blue Cross RochesterMedicaid CB AdvantageMedicare Choice BlueMediPlan Choice CareNew Compensation Community BlueNo Fault Community CareNorth AmeriCare Traditional BlueNOVA Child Health PlusMonthly Payments CignaPreferred Care ChampusSelf Pay EmpireSliding Payment Scale Family Health PlusSenior Blue Fidelis CareSenior Choice Fidelis MedicareUnited Health Care Better Health-FidelisUnivera GHIUnivera Community Health Gold ChoiceUnivera HealthCare Plus Independent Health
Solo or Group Practice:	SoloGroup
Practice Name:
Practice Website:
Primary Practice Address:
City, State, Zip:
Phone:
Fax:
Secondary Practice Address:
City, State, Zip:
Phone:
Fax:
Office Manager Name:
Office Manager Email:
Physician Email:
Interested in presenting at a Community Education program?	YesNo
I authorize Catholic Health to release my name to the public.	YesNo, I DO NOT wish to participate.
Comments:

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Office Update Form

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