Chiro/Acu New Patient Demographic Form

Name: ________________________________________________ Age: ______ Sex: M or F

Address: ___________________________________________________________________

City: _____________________________ State: _________ Zip Code: __________________

Date of Birth: ____________________ Social Security # _________ Marital Status: S M D W

Home Phone: ________________________ Cell Phone: _____________________________

Email: _____________________________________________________________________

Primacy Physician: _____________________________ Phone: _______________________

Referring Physician/Source: ______________________ Phone: _______________________

Emergency Contact: _________________________________________________________

Relationship: __________________________________ Phone: ________________________

I hereby authorize Hudson Wellness to release by mail or electronically, any information needed

by my Insurance Carrier to process claims for payment. I also authorize my Insurance Carrier to

forward payment(s) for Medical and/or Surgical benefits to the Physician(s), i.e. provider of

service at Hudson Wellness. I understand that I am financially responsible for all services

rendered to me whether they are or are not covered by my insurance.

Patient’s Signature: ______________________________________ Date: __________________

Consent to the Use and Disclosure of Health Information for Treatment, Payment, or

Health Operations

I understand that as part of my healthcare, this organization originates and maintains health

records describing my health history, symptoms, examination and test results, diagnoses,

treatment, and any plans for future care of treatment. I understand that this information serves as:

A basis for planning my care and treatment

A means of communication among the many health professionals who contribute to my

care

A source of information for applying my diagnosis and surgical information to my bill

A means by which a third-party payer can verify that services billed were actually

provided

A tool for routine healthcare operations such as assessing quality and reviewing the

competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more

complete description of information uses and disclosures. I understand that I have the right to

review the notice prior to signing this consent. I understand that I have the right to object to the

use of my health information and directory purposes. I understand that I have the right to request

restrictions as to how my health information may be used or disclosed to carry out treatment,

payment, or healthcare operations and that the organization is not requires to agree to the

restrictions requested. I understand that I may revoke this consent in writing, except to the extent

that the organization has already taken action in reliance thereof.

Print Patient Name: _____________________________________________________________

Signature: _____________________________________________________________________

Legal Representative: ____________________________________________________________

Date: ______________________________________

Consent to Treat

I, ___________________________________ do hereby authorize the physicians at Hudson

Wellness to administer such care that is necessary for my particular case. This care may include

consultation or any other procedure which is advisable and necessary for my healthcare. Prior to

any procedures the risk benefits and alternatives have been discussed in detail. In signing below,

I consent to any requested procedures.

_____________________________________________________________________________

Signature Date

_______________________________________________

Name (Printed)

_____________________________________________________________________________

Signature of Parent or Guardian (if patient is a minor) Date

_____________________________________________________________________________

Relationship to Patient

*If pregnant, please notify the Doctor before treatment

Cancellation Policy

Effective January, 2016

We understand that unanticipated events may happen. However, appointments that are missed

and not cancelled prevent other guests access to our facility. In order to provide wellness services

to as many guests as possible, we require 24 hours advanced notice for cancellation.

If you are unable to provide 24 hours advanced notice for cancellation, you will be charged a

$50 cancellation fee.

To change or cancel an appointment, please call our office at 646-882-6278 as soon as possible.

I understand that I will be charged a cancellation fee of $50 in the event that my appointment is

not cancelled within the above mentioned time frame. A credit card authorization will be held on

file to accommodate the charge. This fee must be paid in full prior to future services and

appointments.

Signature Date

Credit Card Authorization Form- Cancellations

Please complete and sign this form to authorize Hudson Wellness to charge your debit or credit

card listed below. By signing this form, you give permission to debit your account for the

amount indicated in agreement with our cancellation policy.

I, ___________________________________ authorize Hudson Wellness to charge my account

listed below for $50. This payment is for a cancellation fee in accordance with the Cancellation

Policy provided to me by Hudson Wellness Center.

Billing Address ________________________________________________

City ___________________________________________________

State ______________________________ Zip Code ____________

Phone: _________________________________________________

I authorize the above named business to charge the credit card indicated in this authorization

form according to the terms outlined above. This payment authorization is for the amount

indicated above ONLY. I certify that I am an authorized user of this credit card and that I will

not dispute the payment with my credit card company, so long as the transaction corresponds to

the terms indicated in this form.

Signature Date

Account Type:

Visa MasterCard AMEX Discover

Cardholder Name: ________________________________________________________________

Account Number: ________________________________________________________________

Expiration Date: _______________________

CVV2 (3-digit code on back of VISA/MC, 4-digit code on front of AMEX): _______

Office and Financial Policies

Payment is expected at the time of your visit. We will accept cash or credit card. Payment will

include any unmet deductible, co-insurance, co-payments amount, or non-covered charges from

your insurance company. If you do not carry insurance, or if your coverage is currently under a

pre-existing insurance clause, payment in full is expected at the time of your visit. A copy of a

valid ID card or license is required for identification purposes.

Insurance We will file all insurance claims. Please remember that insurance is a contract

between the patient and the insurance company and the patient is ultimately responsible for the

payment in full. If your insurance company does not pay the practice in a reasonable amount of

time, you will be billed. If we later receive payment from your insurer, we will refund any

overpayment.

If our providers are not listed in your plan’s network, you may be responsible for partial or full

payment. If you are insured by a plan with which we have no prior arrangement, we will prepare

and submit the claim for you on an unassigned basis. This means the insurer may send the

payment directly to you. Please contact the office immediately when you receive a check from

your insurer.

Verification of insurance benefits is an estimate, therefore we cannot guarantee your eligibility

and coverage. We suggest you check your individual insurance benefits regarding covered

services and providers prior to your appointment. You are responsible for obtaining a properly

dated referral if required by your insurer. Furthermore, you are responsible for payment if your

claim is rejected for lack of proper referral documentation.

Cancellations or Missed Appointments If proper notice of cancellation is not provided for a

missed appointment, you will be charged a $50 cancellation/no show fee. (Please refer to the

designated cancellation policy form for additional information)

Late Charges of 12% annually will be applied to all patient balances 90 days old or greater.

Returned Checks will incur a $30 service charge. You will be asked to bring cash, certified

funds or a money order to cover the amount of the check plus the $30 service fee. This must be

taken care of prior to receiving future services. All bad checks written to this office are subject to

collections and will be prosecuted in New York County.

Accounting Principles Payment and credits are applied to the oldest charges first, except for

insurance payments which are applied to the corresponding dates of service.

Forms Fees We require prepayment for completing forms, copying medical records,

notarization, or extra written communication by the providers. The charge is determined based

on complexity of the form, letter, or communication. Base fees are $10 per occurrence plus any

applicable postage or notary fees. Medical Records fees reflect $10 for the first twenty pages

and then $0.25 per page after that. Hudson Medical Wellness will have fifteen business days

from the payment date in which to copy records before making them available for pickup.

Billing Office If you have questions in regards to any of your billing statements, please contact

our accounts receivable staff at 646-596-7386.

Responsibility for Payment

I understand that I, personally, am financially responsible to Hudson Medical Wellness, PC for

charges not covered by the assignment of insurance benefits.

Assignment of Insurance Benefits

I hereby assign, transfer, and set over directly to Hudson Medical Wellness, PC sufficient monies

and/or benefits for basic and major medical to which I may be entitled for professional and

medical care, to cover the costs of the care and treatment rendered to myself or my dependent in

said clinic. I authorize Hudson Medical Wellness, PC to contract my insurance company or

health plan administrator and obtain all pertinent financial information concerning coverage and

payments under my policy. I direct the insurance company or health plan administrator to release

such information to Hudson Medical Wellness, PC. I authorize Hudson Medical Wellness, PC to

release all medical information (including, but not limited to, information on psychiatric

conditions, sickle cell anemia, alcohol and drug abuse, and HIV or communicable diseases)

requested by my health insurance carrier, Medicare, or other physicians or providers, and any

third-party payers.

Release of Information

I hereby authorize and direct Hudson Medical Wellness, PC to release to government agencies,

insurance carriers, or others who are financially liable for such professional and medical care, all

information needed to substantiate claim and payment.

Collection Fees

I understand that in the event my account is placed in collection status, any additional fees

incurred due to this will be added to my outstanding balance. This includes, but is not limited to,

late fees, collections agency fees, court costs interest and fines. I understand that these additional

fees will be my personal responsibility to pay in full.

I have read and understand the practice’s financial policy and I agree to be bound by its terms,

and such terms may be amended by the practice at any time.

__________________________________________ _____________________

Signature of Patient (or Guarantor, if applicable) Date

__________________________________________

Printed Name of Patient

Health History

AIDS/ HIV Yes/No

Alcoholism Yes/No

Allergy Shots Yes/No

Anemia Yes/No

Anorexia Yes/No

Appendicitis Yes/No

Arthritis Yes/No

Asthma Yes/No

Bleeding Disorders Yes/No

Breast Lumps Yes/No

Bronchitis Yes/No

Bulimia Yes/No

Cancer Yes/No

Cataracts Yes/No

Chemical Dependency Yes/No

Chicken Pox Yes/No

Depression / Anxiety Yes/No

Diabetes Yes/No

Emphysema Yes/No

Epilepsy Yes/No

Fractures Yes/No

Glaucoma Yes/No

Goiter Yes/No

Gonorrhea Yes/No

Gout Yes/No

Headaches Yes/No

Heart Disease Yes/No

Hepatitis Yes/No

Hernia Yes/No

Herniated Disk Yes/No

Herpes Yes/No

High Blood Pressure Yes/No

High Blood Cholesterol Yes/No

Kidney Disease Yes/No

Liver Disease Yes/No

Measles Yes/No

Miscarriage Yes/No

Mononucleosis Yes/No

Multiple Sclerosis Yes/No

Mumps Yes/No

Osteoporosis Yes/No

Pacemaker Yes/No

Parkinson’s Disease Yes/No

Pinched Nerve Yes/No

Pneumonia Yes/No

Polio Yes/No

Prosthesis Yes/No

Psychiatric Care Yes/No

Rheumatoid Arthritis Yes/No

Rheumatic Fever Yes/No

Scarlet Fever Yes/No

Stroke Yes/No

Suicide Attempt Yes/No

Thyroid Problems Yes/No

Ulcers Yes/No

Urinary Tract Infections Yes/No

Vaginal Infections Yes/No

Venereal Disease Yes/No

Whooping Cough Yes/No

Other: ____________________

__________________________

__________________________

__________________________

Exercise None

Moderate

Daily

Heavy

Work Activity

Sitting

Standing

Light Labor

Heavy Labor

Habits

Smoking Packs/Day _______

Alcohol Drinks/Week _______

Coffee/Caffeine Cups/ Day _______

High Stress Level Reason _____________

Are you pregnant? YES / NO Due Date: _____________________________

Injury and Surgery History

Falls Description __________________________________________ Date: _________

Head Injuries Description __________________________________________ Date: _________

Broken Bones Description __________________________________________ Date: _________

Dislocations Description __________________________________________ Date: _________

Surgery Description __________________________________________ Date: _________

Medications: ___________________________________________________________________________

Allergies: _____________________________________________________________________________

Vitamins / Herbs / Minerals: ______________________________________________________________

Family History (please circle)

High Blood Pressure HIV Positive Heart Disease Emphysema Asthma Diabetes Stroke

Back Problems Ulcer or Stomach Problems Arthritis-Rheumatism Headaches Thyroid Disease

Circulation problems Cancer

Name: ____________________________________________________ Date: ______________

What brought you here today? _____________________________________________________

______________________________________________________________________________

Place an “X” on the drawing indicating the

areas causing your pain and letter describing

it.

A= Ache B= Burning S= Stabbing

N= Numbness P= Pins and Needles

Front Back

Pain Scale

Please circle the number that best describes

your pain

0 1 2 3 4 5 6 7 8 9 10

None Little Medium Severe

Describe the cause of the illness: _________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

When did your symptoms appear? __________________________________________________

Is this condition getting progressively worse? _________________________________________

Type of Pain: Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling

Cramps Stiffness Swelling Other: _______________________________________________

How often do you have this pain? Is it constant or does it come and go?

_____________________________________________________________________________

Does it interfere with: Work / Sleep / Daily Routine / Recreation

Activities or movement that is painful to perform: Sitting / Standing / Walking / Bending / Lying Down

What treatments have you already received for your condition? Medical / Physical Therapy / None /

Other: ________________________________________________________________

Patient Signature: __________________________________________________________________