COVID-19 (Coronavirus) Updates: What You Need to Know from our local hospital, UPMC Chautauqua. Click here for more information.

For Patients

For your convenience, please print and fill out all applicable forms and present them at check in when you arrive for your first visit.

Financial Responsibility

Financial Agreement and Assignment of Benefits
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Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
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New Patient Information

New patient demographic and insurance information.
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Records Release

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS related Information. DOH-5032.
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Charge Description and Price List

Patients should check with their insurance company directly for specific coverage information for your plan/insurance coverage. If you do not have health insurance you may qualify for a discount, please see the Financial Agreement section. If you would like a written price estimate please contact our billing office at 716-672-5420

Contact Preferences

Indicate ways that GLPP may communicate information with you.
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