NEW PATIENT FORM

NEW PATIENT INFORMATION FORM

It is very important you fill out all of the fields to the best of your ability. We may ask you to provide the same information more than once. This is very helpful. We apologize for any inconvenience.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Sex *

Male Female
Marital Status
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number

EMERGENCY CONTACT INFORMATION
Emergency Contact

First Name Last Name
Emergency Contact Home Phone Number

Area Code Phone Number
Emergency Contact Cell Phone Number

Area Code Phone Number
Date of Birth of Emergency Contact

Month Day Year
Date

INSURANCE INFORMATION
Primary Insurance (Commercial / State / Federal Insurance Company / Carrier) (*Skip this if you have Workers Compensation or No Fault* You will be asked for information regarding Workers Compensation or No Fault at a later point.)
(Ex. MVP, Empire BCBS, Aetna, Medicare, Medicaid etc.)
Primary Insurance Policy Holder

First Name Last Name
Date of Birth of Primary Insurance Policy Holder

Month Day Year
Date
Effective Date of Primary Insurance

Month Day Year
Date
Policy Number of Primary Insurance
Group Number of Primary Insurance
Secondary Insurance (Commerical / State / Federal)
(Ex. MVP, Empire BCBS, UHC, AARP, Medicaid etc.)
Policy Number of Secondary Insurance
Group Number of Secondary Insurance

PHARMACY INFORMATION
Pharmacy Name and Location (Ex. Drug Store - Rt 9, Poughkeepsie)
PRIMARY CARE PHYSICIAN INFORMATION
Primary Care Physician

First Name Last Name
Primary Care Physician Phone Number

Area Code Phone Number
Primary Care Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
REFERRING PHYSICIAN INFORMATION
Referring Physician Name

First Name Last Name
Referring Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Referring Physician Specialty

WORKERS COMPENSATION and/or NO FAULT INFORMATION
Workers Compensation / No Fault Carrier
WC / NF - Date of Injury

Month Day Year
Date
WC / NF Body Part(s) Covered
WC / NF - Adjuster/Representative Name
WC / NF - Adjuster/ Representative Phone Number

Area Code Phone Number
WC / NF - Carrier Claim Number
WC (Only) - WCB Number
WC / NF - Claim Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

CLINICAL INFORMATION

It is very important you fill out all of the following fields to the best of your ability. We may ask you to provide the same information more than once. This is very helpful. We apologize for any inconvenience this may cause and we thank you for taking the time to complete this form.
Your Name *

First Name Last Name
Referred By

First Name Last Name
Your Height (ft, inches) *
Your Weight (lbs) *
Age *
Sex

Male Female
Approximately how long ago did your pain begin?

Day Month Year
Date
Describe event(s) related to the start of your pain
Please describe the location of the pain *

SURGICAL PROCEDURE HISTORY
Document any surgical procedures you have had (if possible, by dates)
ALLERGIES
Allergies *

Yes, I have allergies No, I do not have allergies
If yes to previous question, please tell us what you are allergic to and the reaction you have:
MEDICATION LIST
Please list any medications you are currently taking, with their doses and number of times taken per day. Include "over the counter" drugs and herbal supplements. If you are not taking any medication, please type "N/A". *

FAMILY HISTORY
Are any of your family members currently suffering from or have passed away from the following? If so, please enter their relationship to you in the box below.
Cancer
Diabetes
Kidney disease
Chronic Pain
Alcohol Abuse
Illegal Drug Abuse
Prescription Drug Abuse
PERSONAL HISTORY
If you are currently working, please enter your occupation below.
If you are currently on disability OR have a pending application please enter the reason for disability.
If you have an open Worker’s Compensation case please click the box below.

Worker's Compensation

LEGAL
If you have a pending litigation related to your pain click the box below.

Litigation
If you have an attorney for your pending litigation related to your pain, please enter your attorney's first and last name below.

First Name Last Name
LIVING STATUS
I live alone I live with my spouse I live with a Domestic Partner / Friend / Kid(s)
PERSONAL HABITS / INFORMATION
Tobacco Use. Please enter the number of cigarettes and how long you have used tobacco in the box below.
Alcohol Use. Please enter how often you drink alcohol in the box below.
If you have a history of using street drugs, please list them in the box below,
Please enter the date you last used street drugs.

Month Day Year
Date
Please select any of the options below that apply to you.

I have been addicted to prescription drugs in past I have been treated for alcohol/ drug abuse in past I have been sexually abused in past

CONSENT FORMS

Please fill out the following consent forms.
Your Name

First Name Last Name
Today's Date *

Month Day Year
Date
I, the patient named above, consent to treatment by providers of North American Partners in Pain Management. *

I consent

Consent to Use and Disclose Protected Health Information (PHI)
I give my consent to the provider and his or her agents to use or disclose my Protected Health Information to carry out treatment, payment, or health care operations. These individuals and entities can release, use, or disclose my PHI to other physicians, nursing practitioners, physician assistants, students in each of the above disciplines, and other such entities or persons as are deemed related to treatment, payment, and health care operations, as determined for the sole discretion of the provider and his or her respective agents. If another provider who is involved with treatment, payment, or health care operations relating to my care requests my medical records, I consent to release my entire medical record maintained by North American Partners in Pain Management, LLP to those requesting providers.I agree, as part of this consent for payment operations, that the provider, its group, their billing personnel, billing agents or Management Company can disclose billing information to any person that calls the provider with billing questions, as long as that person is able to provide the correct social security number and health plan information.I agree that the provider, their agents, or their representatives may call and leave a voicemail message at my home or other number I have provided regarding medical appointments, billing or payment issues, or other information related to treatment, payment, or healthcare operations.I agree that the provider may discuss my PHI with any person that accompanies me to any appointment.The provider may rightly assume that if another person is with me, I have no objection to disclosure of my PHI to that person. I also agree, that the provider may discuss my PHI with any person that identifies him or herself as active in my mental, physical, emotional, or spiritual care, including but not limited to family, friends, clergy, and patient advocates. I also agree, that the provider and his or her agents may disclose my PHI to employers who arrange and pay, directly or indirectly, for my medical treatment.I agree that the provider and their agents may discuss my child’s PHI with the person accompanying the child. I agree that the provider may discuss PHI with both natural parents and stepparents. I acknowledge that state law may grant my child certain privacy rights regarding their PHI and that I have no right to receive this information. I agree the provider and his or her agents may, upon request, disclose my PHI to public health agencies, law enforcement, and the FDA.I acknowledge that I have received a copy of a separate document entitled “Notice of Privacy Practice”which sets forth my rights regarding privacy of my PHI.
Patient Name *

First Name Last Name
Today's Date *

Month Day Year
Date
By clicking the box below, I am agreeing to the terms and conditions listed above. *

I agree

Release and Assignment
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, Blue Shield, HMOs and commercial insurance to North American Partners in Pain Management, PLLC.North American Partners in Pain Management, PLLC will bill only for the professional component of these services.I understand that I am financially responsible for all charges for the hospital and for anesthesia if these services are used.I understand that I am financially responsible for all charges whether or not covered by said insurance.I authorize release of any information required to secure payment on my behalf.I am aware that there is a $30.00 late cancellation fee for any appointment or procedure that is not cancelled at least 24 hours in advance.I request that any payments of authorized Medicare benefits be made either to me or on my behalf to North American Partners in Pain Management, PLLC, for services furnished to me by the provider.I authorize any holder of medical information about me, to release to the Health Care Financing Administration and its agencies any information needed to determine these benefits or the benefits payable for related services.
Patient Name *

First Name Last Name
Today's Date *

Month Day Year
Date
By clicking the box below, I am agreeing to the terms and conditions listed above.

I agree
Should be Empty:

NEW PATIENT INFORMATION FORM

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

PHARMACY INFORMATION

PRIMARY CARE PHYSICIAN INFORMATION

REFERRING PHYSICIAN INFORMATION

WORKERS COMPENSATION and/or NO FAULT INFORMATION

CLINICAL INFORMATION

DESCRIPTION OF PAIN

AVERAGE DAILY PAIN

HOW DO THE FOLLOWING AFFECT YOUR PAIN?

INDICATE THE LEVEL OF RELIEF FROM EACH ACTIVITY

DIFFICULT ACTIVITIES

REVIEW OF SYSTEMS

MEDICAL HISTORY

SURGICAL PROCEDURE HISTORY

ALLERGIES

MEDICATION LIST

FAMILY HISTORY

PERSONAL HISTORY

LEGAL

LIVING STATUS

PERSONAL HABITS / INFORMATION

CONSENT FORMS

Consent to Use and Disclose Protected Health Information (PHI)

Release and Assignment