To help make your life easier, we give you quick access to a variety of forms, all in one convenient location
Use this form to request medical records for yourself or to send to a provider/entity that is not listed as one of your providers in your intake paperwork.
This form is used to file a written grievance or incident report that occurred while at or with any staff of WNYBC. All patients and/or patient’s families may submit a written grievance and/or incident report without fear of reprisal.
The HIPAA Authorization Revocation Form is provided to you in the event you change your mind and do not authorize WNYBC to share your PHI as noted on your HIPAA Authorization Form. A written request/form can be sent to WNYBC at any time. Please refer to the Notice of Privacy Practices.
Use this form to request medical records for a patient of WNYBC.
At Western New York BloodCare, we understand how daunting self-infusing your factor products can be. Our clinical staff wanted to provide an educational resource for both patients and caregivers on the step-by-step process of self-infusing. We hope this video proves to be helpful, and if you’re still left with any questions or concerns please reach out to our nursing staff by calling us at (716) 896-2470.
WNYBC prides itself on being a great resource for those within the bleeding disorders community. Below are some useful links for your reference. Never hesitate to call the office at (716) 896-2470 if you need additional assistance.
HANDI is NHF’s Information Resource Center. Be informed on how to receive emergency alerts that may affect your area.
- National Hemophilia Foundation
- National Hemophilia Foundation Steps for Living
No matter what your life stage, this section delivers all the essential facts you need to know about bleeding disorders.
- Victory for Women- Resource for Women with Bleeding Disorders
- National Hemophilia Alliance
The Alliance is a not-for-profit organization that currently comprises 95 Hemophilia Treatment Centers. The purpose of the Alliance is to assist its members in providing outstanding care for their patients.
- World Federation of Hemophilia
The World Federation of Hemophilia improves and sustains care for people with inherited bleeding disorders around the world.
- Hemophilia Federation of America
The national community-based advocacy organization serving all people living with bleeding disorders and their families across the United States.
- New York State Bleeding Disorders Coalition
A partnership of not-for-profit organizations dedicated to public advocacy on behalf of people affected by bleeding disorders in New York State.
Other Bleeding and Clotting Disorders:
- Platelet Disorder Support Association
Comprehensive information and support for those concerned about ITP, immune thrombocytopenia.
- National Blood Clot Alliance
The National Blood Clot Alliance (NBCA) sees a future in which the number of people suffering and dying from blood clots in the United States is reduced.
The Bleeding Disorders Magazine
- Foundation for Women and Girls with Blood Disorders
Undiagnosed, untreated blood disorders in women and young girls have medical consequences and unique issues at every life stage, creating the need for a foundation dedicated to education and awareness.
There are many continuing changes within health insurance today. Even with a great insurance policy, always be sure to understand your coverage. WNY BloodCare stresses the importance of knowing every aspect of your insurance policy coverage and regulations, as they are varied.
Many insurance plans now require a preauthorization and/or pre-certification for hemophilia services. Preauthorization equals permission to receive certain outpatient services. Pre-certification equals medical necessity for a requested service (i.e. factor).
Understand the difference between these terms:
- Deductible – a fixed dollar amount you must pay before your plan begins to pay.
- Co-payments – a set amount you pay each time you have a hemophilia related service (some insurances are taking a co-pay on factor now).
- Coinsurance – percentage of the cost of your care for which you are responsible (for example 80/20 – the Center receives the 80% from the insurance company and you pay the 20%). Some policies, however, are as high as 50/50, which could result in your responsibility for thousands of dollars.
It is very important to know which of the above apply to your individual policies.
Most pharmaceutical companies offer patient assistance programs designed to ensure that our patients are able to continue to receive their medication even if they lose their health insurance coverage or are underinsured and cannot afford their co-pays or coinsurance on their medication (i.e. free trial programs, co-pay assistance programs, free factor programs, etc.).
If you are interested in any of the above patient assistance programs, are experiencing a current issue with your health insurance, or are expecting an impending change in your insurance, please contact us at (716) 218-4007 for assistance.
If you have a specific question regarding your insurance policy, please contact our Accounts Receivable Specialist at 716-896-2470 ext. 4005 or 716-218-4019.
No Surprises Act – New York State
Understanding the No Surprises Act Law:
Surprise Billing Protection Form:
This document describes your protections against unexpected medical bills. It also asks if you’d like to give up those protections and pay more for out-of-network care.
This notice is to make you aware that your provider or this facility isn’t in your health plan’s network and is considered out of-network. This means your provider or facility doesn’t have an agreement with your plan to provide services.
Getting care from this provider or facility will likely cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills when:
- You’re getting emergency care from an out-of-network provider or facility, or
- An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without your consent to receive a higher bill.
Ask your health care provider or patient advocate if you’re not sure if these protections apply to you. If you sign the provided form, be aware that you may pay more because:
- You are giving up your legal protections from higher bills.
- You may owe the full costs billed for the items and services you get.
- Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.
Before deciding whether to sign the form you will be provided, you can contact your health plan to find an in-network provider or facility. If there isn’t one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs.
Consumer Complaint Contact Information:
You can submit a complaint about a medical billing experience you had whether insured or uninsured, visit CMS No Surprises Act – Consumers Information or call the CMS No Surprises Help Desk: 1-800-985-3059 from 8:00am – 8:00pm EST 7 days a week. You can also contact the NYS Consumer Assistance Program for further assistance.
This web site may contain links to other sites. Please be aware that we are not responsible for the content or privacy practices of such other sites.
Western New York BloodCare Compliance Hotline: (716) 218-4005
The Compliance Hotline for the Western New York BloodCare is a private, dedicated phone line in which staff, patients, vendors and others can report concerning and/or suspicious activity associated with the Center.
The Compliance Office will not attempt to trace your call or determine who you are. Please leave a message with your compliance concern in as much detail as possible. If you would like the Compliance Office to follow up with you directly, please also leave a number where we may contact you.