• Levittown New Patient Intake Packet

  • In an effort to keep our records as updated as possible and to communicate with you and other healthcare providers more effectively, please provide us with the following information:

  • Format: (000) 000-0000.
  • Cell Phone Carrier

  • We Are Completely Committed To Improving Your Health Through Chiropractic Care!

  • Chiropractic Registration and History

  • Patient Information

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status

  • Insurance

  • Relationship to patient
  • Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is patient covered by additional insurance?

  • ASSIGNMENT AND RELEASE

  • I, the undersigned, certify that I (or my dependent) have insurance coverage with    and assign directly to DR. Bernstein all insurance benefit, if any, otherwise is payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Phone Numbers

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IN CASE OF EMERGENCY, CONTACT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Accident Information

  • Is condition due to an accident?
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type of accident
  • To whom have you made a report of your accident?

  • Patient Condition

  • Is this condition getting progressively worse?
  • Type of Pain
  • Does it interfere with your
  • Activities/Movements that are difficult to perform
  • Mark an X on the picture where you continue to have pain, tingling or numbness

  • Health History

  • What treatment have you already received for your condition? (Please select all that apply)
  • Have you received Chiropractic care?

  • Family Health History

  • Please check the box to indicate if you have had any of the following. If you have not, please leave the box unchecked:
  • For Females
  • For Males
  • Are you pregnant?
  • Due Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Exercise Level
  • Work Activity
  • Social Habits

  • Patient Consent For Use And/ Or Disclosure of Protected Health Information To Carry Out Treatment, Payment and Healthcare Operations

  •    hereby states that by signing this consent, I acknowledge and agree as follows:

    1. The office of Michael A. Bernstein, DC, PC (hereafter known as The Practice) Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information (“PHI”) necessary for The Practice to provide treatment to me, and also necessary for The Practice to obtain payment for that treatment and to carry out its healthcare operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the privacy notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.
    2. The Practice reserves the righ to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law.
    3. I understand that, and consent to the following appointment reminders that will be used by the practice:
      1. A postcard mailed to me a the address provided to me
      2. Telephoning my home and leaving a message on my answering machine or with the individual answering the phone
      3. Using email and/or text messages at the email address/ phone number provided by me.
    4. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for The Practice to treat me and obtain payment for that treatment, and as necessary for The Practice to conduct its specific health care operations.
    5. I understand that I have a right to request that The Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment, and/or health care operations. However, The Practice is not required to agree to any restrictions that I have requested. If The Practice agrees to a requested restriction, then the restriction is binding on The Practice.
    6. I understand that if I revoke this Consent at any time, The Practice has the right to refuse to treat me.
    7. I understand that if I do not sign this Consent evidencing my Consent to the uses and disclosures described to me above, and contained in the Privacy Notice, then The Practice will not treat me.

    I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year

  • Informed Consent to Chiropractic Adjustments and Care

  •    I have an opportunity to discuss with the doctor of chiropractic named above and/or with office or clinic personnel, the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

       I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and if necessary, diagnostic X-Rays by the doctor of chiropractic named above and/or anyone working in this clinic authorized by the doctor of chiropractic listed.

       I have been informed that it is not uncommon that patients have some increased discomfort after an adjustment. If that happens I will apply ice to the area and rest it. If I am concerned about this discomfort or develop any new symptoms I can call the number listed above 24 hours a day for emergency attention. If I am out of town or unable to contact the doctor, I can present myself to an emergency room.

       I further understand and am informed that as in all health care, in the practice of chiropractic there are some very slight risks to treatment including, but not limited to, muscle strains and sprains, disc injuries and strokes. I do not expect the doctor to be able to anticipate and explain all risks and complications and I wish time, based upon the facts then known, is in my best interests.

       If any tests were performed outside of this office (laboratory or other diagnostic procedures) I understand that the doctor will notify me of the results at my next scheduled appointment.

       I have read the above consent, as indicated by my initials. I have also had an opportunity to ask questions about this consent and by signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year

  • Assignment and Instruction For Direct Payment to Physician Private, Group, Accident, and Health Insurance

  • I hereby authorize and direct the     Insurance Company to pay by check made out and mailed directly to: 

    Michael A. Bernstein, D.C. 3000 Hempstead Turnpike Suite 112 Levittown NY 11756

    The professional or medical expense benefits allowable and otherwise payable to me under my current policy as payment toward the total charges for professional services rendered.

    THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.

    This payment will not exceed my indebtedness to the above mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.

    A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.

    I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Patient Financial Responsibility

  • Thank you for choosing Dr. Michael Bernstein as your Chiropractor. In order to ensure an optimal experience in the office, please carefully read and sign this form in the indicated spaces acknowledging your understanding of our patient financial policy.

    Insurance Coverage Changes: It is your responsibility to be aware of your insurance coverage. If there are any changes, you must notify us so we can update your chart, and verify your eligibility. If your coverage is not in effect at the time of your visit, the financial responsibility for payment is yours. If you fail to notify us of an update in insurance, so we may submit claims in a timely manner, the responsibility will become yours as well.

    Copayments, Co-Insurance, and Deductibles: The Copay, Co-Insurance and Deductible of a policy is the patients’ responsibility. Copays are due at the time of each visit, prior to leaving the office. The deductible and co-insurance varies between policies, and is based on the contract you have with your insurance carrier. We do not know how much of your deductible has been met at the time of your visit, nor do we know your responsibility, as coinsurance rates vary from policy-policy and the services provided at the time of your visit. The deductible and/or coinsurance rates will be billed to you, and must be paid in a timely manner, so your account does not become outstanding.

    Referrals and Insurance Requests: If your insurance requires a referral from a Primary Care Provider (PCP) for Specialist visits, it is your responsibility to obtain one. As a courtesy, we can assist you in the process of retrieving the referral. If at any time your PCP changes, please notify us as a new referral will need to be obtained. Patients are responsible for responding to any request from the insurance company for further information. If the request is not satisfied in a timely manner, it can result in a denial, making you responsible for payment.

    Non-Covered Services: Patients are responsible for all “non-covered” services if they are denied by their insurance carrier.

    I have read and understand the terms outlined in this Financial Responsibility Form.

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: