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Pay Your Bill Book Online Patient Portal

(315) 451-5400
Pay Your Bill
Book Online
Patient Portal
Home
About
- Meet the Providers
- Locations
Services
Procedures
Patient Forms
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Articles
Contact Us

New Patient – BETA

Home > Patient Forms > New Patient – BETA

No Fault Verification Form

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Worker's Compensation Verification Form

Patient Registration:

Today's Date *

Primary Care Physician *

Patient's First Name: *

Patient's Last Name: *

Email Address: *

Sex: *

Race: *

Address: *

City: *

State: *

Zip: *

Preferred Language: *

Ethnicity: *

Home Phone: *

Cell: *

Social Security Number: *

Date of Birth: *

Age: *

Pharmacy: *

Pharmacy Address: *

Employer: *

Occupation *

Address: *

Phone Number:

Guarantor Information (Person whom Insurance is under)

Name: *

Social Security: *

Date of Birth: *

Phone Number: *

Address: *

City: *

State: *

Zip: *

Relationship to Patient: *

Employer: *

Insurance Information:

Primary:

Insurance Name: *

Date of Birth: *

ID/Policy Number: *

Subscriber Name: *

Employer: *

Group Number: *

Secondary:

Insurance Name:

Date of Birth:

ID/Policy Number:

Subscriber Name:

Employer:

Group Number:

Authorization for Treatment

Signature

I authorize treatment of the named person above and agree to pay all fees and charges for such treatment.

Privacy Policy *

Date: *

Privacy Information

In order to comply with federal regulations regarding your privacy in our office, we ask that you complete the following
questions:

Ok to Leave Information?

On home Phone (including Auto Call)? (Please check the boxes where the answer is YES.)

Appointment Information Medical Information Billing Information All Information

On Cell Phone (including Auto Call)? (Please check the boxes where the answer is YES.)

Appointment Information Medical Information Billing Information All Information

On Office Voice Mail? (Please check the boxes where the answer is YES.)

Appointment Information Medical Information Billing Information All Information

With another person? (Please check the boxes where the answer is YES.)

Appointment Information Medical Information Billing Information All Information

Send via mail? (Please check the boxes where the answer is YES.)

Appointment Information Medical Information Billing Information All Information

Send via email? (Please check the boxes where the answer is YES.)

Appointment Information Medical Information Billing Information All Information

If you answered YES to allowing us to discuss your appointment, medical, billing and/or all information with another person, please list their name(s), relationship(s), and phone number below:

Additional HIPAA Contact Instructions:

Do we have your permission to obtain your medication history from the pharmacy? *

Doctors or Facilities that participate in your healthcare (Name, Address, Phone, and Fax):

I acknowledge that I have been provided a copy of CNY Spine and Pain Medicine, LLC Notice of Privacy Practices and have been given the opportunity to have my questions answered.

I acknowledge that I have been provided a copy of CNY Spine and Pain Medicine, LLC Notice of Privacy Practices and have been given the opportunity to have my questions answered.

Privacy Practices *

Authorization for Access to Patient Information Through a Health Information Exchange Organization

Patient Name: *

Date of Birth: *

Other Names Used (e.g., Maiden Name):

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow the Organization named above to obtain access to my medical records through the health information exchange organization called HealtheConnections. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. HealtheConnections is a not-for-profit organization that shares information about people’s health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn more visit HealtheConnections website at http://healtheconnections.org/.

My information may be accessed in the event of an emergency, unless I complete this form and check box #3, which states that I deny consent even in a medical emergency.

The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.

My Consent Choice. ONE box is checked to the left of my choice.

I can fill out this form now or in the future.
I can also change my decision at any time by completing a new form

Consent

1. I GIVE CONSENT for the Organization named above to access ALL of my electronic health information through HealtheConnections to provide health care services (including emergency care).

2. I DENY CONSENT for the Organization named above to access my electronic health information through HealtheConnections for any purpose, even in a medical emergency

If I want to deny consent for all Provider Organizations and Health Plans participating in HealtheConnections to access my electronic health information through HealtheConnections, I may do so by visiting HealtheConnections
website at http://healtheconnections.org/ or calling HealtheConnections at 315.671.2241 x5.

My questions about this form have been answered and I have been provided a copy of this form.

My questions about this form have been answered and I have been provided a copy of this form.

Privacy Policy *

Opioid Assessment Tool

Please Check Either Yes or No for Each Row Below

1. Family history of substance abuse

1. Alcohol *

Yes No

2. Illegal drugs *

Yes No

3. Rx drugs *

Yes No

2. Personal history of substance abuse

4. Alcohol *

Yes No

5. Illegal drugs *

Yes No

6. Rx drugs *

Yes No

3. Age between 16-45 years *

Yes No

4. History of preadolescent sexual abuse *

Yes No

5. Psychological disease

7. ADD, OCD, bipolar, schizophrenia *

Yes No

8. Depression *

Yes No

Patient Name *

DOB *

I confirm that the information provided on this page is accurate to the best of my knowledge.

I confirm that the information provided on this page is accurate to the best of my knowledge.

Privacy Policy *

Patient Pain Profile

Patient Name: *

Date: *

Patient Date of Birth: *

Patient Height: *

Patient Weight: *

Primary Care Physician: *

1. Location of Pain: *

2. Please describe your current pain level with 0 being No pain and 10 Severe Pain. *

1

3a. What is your pain level with medications: *

3b. What is your pain level without medications: *

4. Please check the boxes by the words that best describe your pain: *

Constant Intermittent Dull Sharp Achy Stabbing Throbbing Itching Spasms Skin Crawling Numb Tingling Electric Shock-like Burning

5. Where does the pain radiate to? *

6. What improves your pain (ex. rest, medications, and position)? *

7. What worsens your pain (ex. position, exercise, and activity)? *

8. Medical changes since last visit including surgeries or imaging: *

9a. What is/was your job/occupation? *

9b. Are you currently working? *

10a. Currently On:

No Fault Worker's Compensation Disability

10b. Date Last Worked:

11. Treatments tried and WHEN? *

12. Did you have an injection since your last office visit? *

What is your percentage of relief?

10

What activities were you able to perform after the injection that you could not prior to the injection?

Serving the Needs of Central NY

CBD for Medical Pain Contact Us

Office Locations

Morgan Road Office

7449 Morgan Road
Liverpool, NY 13090
Get Directions
Utica Office

6 Business Park Court
Utica, NY 13502
Get Directions
Camillus Office

5301 W Genesee Street
Camillus, NY 13031
Get Directions

Procedure Locations

CNY Spine and Pain Medicine, LLC.
7449 Morgan Road
Liverpool, NY 13090

Contact Us
APEX Surgical Center
5325 State Route 233
Westmoreland, NY 13490

apexsurgery.com
Specialty Surgery Center of CNY
225 Greenfield Parkway
Liverpool, NY 13090

sscofcny.com

Our Affiliates

Hours: Mon-Fri 8:00am-4:00pm

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