New Patient Intake Form

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Patient Information

Emergency Contact

Insurance Information

Policy Holder

Complaint Summary:

Health Summary


This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information, this is known as HIPAA. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances.

Permitted Disclosures:

  • Treatment purposes - discussion with other health care providers involved in your care
  • Inadvertent disclosures - open treating area means open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room
  • For payment purposes - to obtain payment from your insurance company or any other collateral source
  • For worker’s compensation purposes - to process a claim or aid in investigation
  • Emergency - in the event of a medical emergency, we may notify a family member
  • For public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public
  • To governmental agencies or law enforcement - to identify or locate a suspect, fugitive, material witness, or missing person
  • For military, national security, prisoner, and government benefits purposes
  • Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death
  • Telephone calls or emails and appointment reminders - we may call your home/cell and leave voice/text messages regarding an appointment, a missed appointment, or notify you of changes in practice hours or upcoming events
  • Announcing names in queue at the front desk & reception area - we announce the first and last names of patients in queue that are waiting to be treated (eg. Jane Smith, please proceed to room 2?). Please notify the office manager if you would like this to be changed
  • Change of ownership - in the event this practice is sold, the new owners would have access to your Personal Health Information

Your rights:

  • To receive an accounting of disclosures
  • To receive a paper copy of the comprehensive Detail Privacy Notice
  • To request mailings to an address different than residence
  • To request restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.


As our patient, you are hereby provided this Bill of Rights you have the right to be notified in writing of your rights and obligations before treatment has begun. The patient's family or guardian may exercise the patient's right when the patient has been judged incompetent. We fulfill our obligation to protect and promote the rights of our patients, including the following:

Patient’s Rights:

As the patient/caregiver, you have the RIGHT to:

  • Be treated with dignity and respect.
  • Confidentiality of patient records and information pertaining to a patient's care.
  • Be presented with information at admission in order to participate in and make decisions concerning your plan of care and treatment.
  • Be notified in advance of the type of care, frequency of care, and the clinical specialty providing care and be notified in advance of any changes in your plan of care and treatment.
  • Be provided equipment and service in a timely matter.
  • Receive an itemized explanation of charges.
  • Express grievance without fear of reprisal or discrimination.
  • Receive respect for the treatment of one's property.
  • Be informed of potential reimbursements for services under Medicare, Medicaid or other third-party insurers based on the patient's condition an insurance eligibility (to the best of the company's knowledge).
  • Be notified of potential financial responsibility for products or services not fully reimbursed by Medicare, Medicaid or other third-party insurers (to the best of the company's knowledge).
  • Be notified within 30 working days of any changes in charges for which you may be liable.
  • Be admitted for service only if the company can provide safe, professional care at the scope and level of intensity needed; if we are unable to provide services then we will provide alternative resources.
  • Purchase inexpensive or routinely purchased a durable medical equipment.
  • Expect that we will honor the manufacturer's warranty for equipment purchased from us.
  • Receive essential information in a language or method of communication that you understand.
  • Each patient has a right to have his or her cultural, psychological, spiritual, and personal values, beliefs and preference respected.
  • To be free from mental physical, sexual, and verbal abuse, neglect, and exploitation.
  • Access, request, and amendment to, and receive an accounting of disclosures regarding your health information as permitted under applicable law.


As the patient/caregiver, you are RESPONSIBLE for:

  • Notifying the company of change of address, phone number, or insurance status.
  • Notify the company when service or equipment is no longer needed.
  • Notify the company in a timely matter if extra equipment or services will be needed.
  • Participating as in the plan of care/treatment.
  • Notifying the company of any change in condition, physical orders, or physician.
  • Notifying the company of an incident involving equipment.
  • Meeting the financial obligations of your health care as promptly as possible.
  • Providing accurate and complete information about president complaints, past illnesses, hospitalizations, medications, and other matters pertinent to your health.
  • Your actions if you do not follow the plan of care/treatment.


As your provider of choice, we have the right to:

  • Terminate services to anyone who knowingly furnishes incorrect information to our company to secure durable medical equipment.
  • To refuse services to anyone who seeks direct care in threatening behavior, intoxicated by alcohol, drugs and/or other chemical substance and will potentially jeopardize the safety our staff and/or patients.

Informed Consent

Please read the document in its entirety prior to signing. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

A patient, in coming to Bensa Chiropractic and Wellness, LLC, gives the doctors permission and authority to care for the patient in accordance with the chiropractic exam, analysis, diagnosis, and treatment of the joints and soft tissues.

As with any healthcare procedure, there are certain complications which may arise during the chiropractic adjustment and other clinical procedures. The chiropractic manipulation and other therapy are usually beneficial and seldom cause any problems. In rare cases, possible complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and physical therapy burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications, including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. We will make every reasonable effort during the examination to screen for contraindications to care; however, it is the responsibility of the patient to make it known, or to learn through health care procedures whatever he or she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the doctors.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which is screened for during the consultation, examination, and x-ray. The incidences of stroke are exceedingly rare and are estimated to occur between once in one million and once in ten million cervical adjustments.

Other treatment options for your condition may include:

• Self-administered, over the counter analgesics and rest

• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants, and pain killers

• Hospitalization

• Surgery

Remaining untreated may allow the formation of adhesions and arthritis and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

I have read or have had read to me the above informed consent and I understand that if I am accepted as a patient by the doctors at Bensa Chiropractic and Wellness, LLC, I am authorizing them to proceed with any treatment that may be necessary. Any questions I have had regarding these procedures have been answered to my satisfaction prior to my signing the consent form. I have made my decision voluntarily and freely.

Terms of Acceptance

In order to provide the most effective healing environment, the most effective application of chiropractic procedures, and the strongest possible doctor-patient relationship, it is essential for both parties to be working toward the same objective. It is important that each person understands both the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment.

• Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. It is not the practice of medicine.

• Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functions through the adjustments of vertebral subluxation(s). Subluxations are deviations from normal spinal structures and configurations and considered to be a partial dislocation. A subluxation that interferes with normal nerve processes is called a neuro-structural shift.

• The chiropractic adjustment process, as defined in the law of this jurisdiction, involves the application of a specific directional thrust to a region or regions of the spine with the specific intent of re-positioning misaligned spinal segments. This is a safe, effective procedure applied over one million times a day with Doctor of Chiropractic in the United States alone.

• Chiropractic does not seek to replace or compete with your medical, dental, or other type(s) of health professionals. They retain responsibility for care and management of medical conditions. We do not offer advice regarding treatment prescribed by others.

Office Financial Policy

Thank you for choosing Jose Benejan Lorenzo DC/Nicole Santana Rodriguez DC as your health care provider. We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Office Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any changes to your patient information (i.e., address, name, insurance information, etc.) prior to receiving services.

It is our office policy that payment for services rendered is ultimately the responsibility of the patient, whether you have third-party assistance with your financial obligation or not. All payments for services rendered are expected at the time of service unless one of the following applies:

  • Agreed to a preset payment plan. We are happy to extend a payment plan to you so that you can follow through with all the care you require.
  • Enrolled in a Discount Medical Plan Organization for services rendered at the clinic such as CHUSA

Personal balances may not exceed $ 50.00 unless on a pre-arranged payment plan. For your convenience, this office accepts cash, checks, and the following credit cards: Visa, MasterCard, American Express, Discover. Should payment be refused by your bank for any check written, this office will charge a fee of $25.00 to offset the charges we will incur as a result of the returned check.

As a courtesy to our patients, this office will bill third party payers that we are in network with, accept assignment and wait to be paid for some portion of our patients' financial responsibility. The privilege of insurance assignment begins when our office receives and verifies your insurance information. Until that time, you are considered a “cash” patient and payment is expected at the time of service. As a courtesy to you, our office will verify your insurance coverage, in an effort to help you determine what coverage is available to you under your policy. We will help you make the best estimate of your coverage for the recommended services. This service is a courtesy to you and is not a guarantee of coverage. No one can predict what an insurance company will pay for the usual and customary charges for services rendered. If we participate in your plan, you will not encounter balance billing above the insurance carrier’s fee schedule. If we do not participate, we will provide a super bill and provide you with a Good Faith Estimate.

If your insurance has not paid on an assigned bill within 30 days, you will be notified. Since we do not manage your policy, we ask that you stay in communication with our office and take action with your insurance company at that time. If it remains unpaid, within 90 days the balance becomes due and payable immediately. Monthly interest charges will be at 1.5% on all unpaid balances after 30 days.

Should you discontinue care for any reason, other than discharge by the doctor, all balances will become due and payable at that time. If you are on a predetermined payment plan, that plan will continue to be in effect until your balance is zero.

I, the undersigned, have insurance coverage with (Health Insurance) Insurance Company and assign directly to Bensa Chiropractic and Wellness, LLC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether paid by insurance. I hereby authorize Bensa Chiropractic and Wellness to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all my insurance submission whether manual or electronic.

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