Patient Forms

Below you will find our Patient Forms, please fill them out in their entirety and make sure to hit the submit button at the end!

Patient Information
Legal Name*

First NameLast Name
Preferred Name:
Date of Birth*

MonthDayYear
Age*
Address:*

Street Address

Street Address Line 2

CityCounty/State/Province

Postal / Zip CodeCountry
Email*
example@example.com
Preferred Phone Number*
Gender

MaleFemale
Marital Status

MarriedSingleDivorcedWidowed
Employer & Occupation
Emergency Contact*

NameRelationship
Emergency Contact Phone*
Please enter a valid phone number.
Where you referred by someone? or How did you hear about us?
I authorize the release of medical information to my insurance company for review of my coverage and/or the processing of claims for services rendered to me.

I permit a copy of this authorization to be used in place of the original.

I Understand I am responsible for any charge incurred that are not covered by my insurance company.
Patient | Parent | Guardian Signature*

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General Consent Form
1. I hereby do voluntarily consent to such care including routine procedures, examinations, tests, or local anesthesia and other treatment by The Center For Holistic Medicine professionals and their assistants, appointees, or consultants as is necessary in their judgement.

2. If I don't fully understand a procedure or its risks, consequences and alternate methods of treatment, I have the right to question the appropriate health care professionals.

3. I understand that blood may be drawn from me for HIV testing without further permission being given by me if a doctor, other health professional, or employee is exposed to my blood or bodily fluid

4. I understand that The Center For Holistic Medicine shall not be responsible or liable for the loss of/or damage to any personal property.

5. I understand that I, or my insurance company will be responsible for payment of any lab work done.

6. I understand that I am welcome to take the requisition (order form) for blood tests and have my blood drawn and tested at any laboratory of my choice or a laboratory contracted with my insurance company. It is my responsibility to know which lab my insurance allows.

7. I understand most traditional (non-HMO or PPO) insurance carriers will apply coverage benefits (subject to my individual contract, co-pays and deductibles) for what my insurance carrier deems medically necessary. Most tests are considered a benefit and medically necessary when ordered by a licensed physician but this may not always be the case. Some test are typically not a covered benefit and require pre-payment by myself (the patient), for these tests to be run. If I have questions or concerns regarding coverage for lab tests, I am to contact my health plan or review my coverage benefits for details on coverage, as it applies to me. I will do this before having my blood drawn at any station or laboratory.

8. I permit a copy of this authorization to be used in place of the original

I have read this form and my questions have been adequately answered and I certify that I understand its contents.
Patient | Parent | Guardian Signature*

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Financial Policy
Thank you for choosing the Center For Holistic Medicine (CHM) as your health care provider. We are committed to providing treatment of the highest quality. As part of the provider/patient relationship, we believe that it is important for you to understand our Financial Policy regarding payment for services. We ask that you review and sign this policy prior to any treatment.

Full payment is due at the time of service. We accept cash, checks, money orders, Visa, Mastercard, Discover, and American Express.

Regarding Insurance Coverage
We are not participating providers with any of the insurance companies. You will have to pay at the time of your office visit. We will use your insurance for lab work done at our office, that is why it is necessary for you to bring in all insurance information.

A receipt will be provided for you to submit to your insurance company for possible reimbursement. Payment is due at the time of service.

Adult Patients:
Adult patients are responsible for full payment at the time of service.

Minors:
The parent or guardians of a minor are responsible for full payment at the time of service.

Credit Risk:
I understand that should I default on payment for services, that my account may be transferred to an independent collection agency, designated as a CREDIT RISK and that payment for services at the time of registration will be required for all future visits in cash. All insufficient funds with checks returned to CHM from the bank a $15.00 charge will be added to my account.

Missed Appointments:
Patients may be charged for missed appointments, at the doctors discretion

I have read the Financial Policy above. I understand and agree to this Financial Policy

Thank you for understanding our Financial Policy. Please let us know if you have any questions.
Patient | Parent | Guardian Signature*

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Request for Treatment
I,First Name* Last Name* , hereby request treatment at CHM. I understand the objectives of this treatment are to improve my/my child's general health and well-being.
Treatment Program: I understand that there may be other treatments and procedures that some physicians might consider more appropriate for these conditions. These other approaches may include:
1. Dietary changes
2. Drug therapy
3. Surgery
4. Watchful waiting-simply wait and watch until my condition improves or becomes worse
5. No treatment at all
6. Another opinion
Patient’s Rights: I understand that
I have the right not to participate in this treatment program for any reason and to discontinue treatment at any time.
I may have a complete copy of this consent for future reference.

History and Physical Exam: I understand that
The necessity to provide a complete and truthful medical history and to undergo a physical exam prior to therapy.
That it may be necessary for my physician to seek consultation with other physicians regarding my condition. This will be discussed with you.

Laboratory Testing: I understand that
It may be necessary for me to undergo certain laboratory tests prior to therapy. These tests may determine whether I have diabetes, elevated cholesterol, liver diseases, kidney disease, anemia, infection, endocrine or other medical issues.

Risks and Possible Side Effects: I understand that
There can be inherent risks in any medical treatment and those known risks will be explained to me

Lasting Benefits: I understand that
Some patients may not receive benefits or may have adverse reactions
Even if benefits occur, symptoms may recur, and additional treatment may be necessary

I have read this document; it has been explained to me and all questions have been answered to my full and complete understanding and satisfaction. I expressly acknowledge that there have been no guarantees made to me as to the benefits or lack of complications from treatment. I also understand that insurance companies may not pay for this treatment
Patient | Parent | Guardian Signature*

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Consent to Share Information

Complete this form if you would like a member of your family to have access to your medical records. Please note, without this form no one but the patient may call to make appointments or access information.
I, First Name Last Name , give my permission for Dr. CHM Provider* , as my doctor at the Center For Holistic Medicine, to speak to Name & Relationship to Patient regarding my medical information.

New Patient Guide Acknowledgement
1st Consult: The 1st consult is up to 45 minutes @ $600. 1st time patients are required to be seen in person. There will be a review of the patient’s health history and daily habits, diet, exercise, medication list, vitamin list, recent labs. etc. The appointment is a mutual dialogue between you & your practitioner. If you do not have any questions, the length of your appointment may require less time. Please note that there is no adjustment to any appointment fees if your appointment is less than the 45-minute time slot. During this time, an initial protocol of vitamins, supplements, IV therapies, etc. may be recommended to treat the condition that is being addressed. Follow up appointments, vitamins, supplements, IV therapies, & additional services are at an additional charge. Prices for supplements and services may be subject to change without notice.

For your first consultation a non-refundable deposit of $300 is required to secure the appointment. The balance of $300 is expected to be paid at the time of checkout. Note that the deposit is non-transferrable.

Lab Appointment: Our healthcare professionals order an extensive panel of tests to include hormone levels, thyroid levels, as well as vitamin and mineral levels. We have a private Quest Lab at our office as a service to our patients. You may also have your labs done at a different location of your choice.

2nd Consult: The second consultation is up to 30 minutes @ $375. This follow-up appointment with your healthcare professional will generally occur 2-10 weeks following your lab appointment, during which time your lab results will be discussed. Based on your lab results, your practitioner may start you on a protocol or adjust protocols established at your first consultation, as well as diet and lifestyle suggestions.

Additional Appointments & Tests: Based on your healthcare professional’s request, there may be subsequent appointments scheduled including follow up visits, IV therapies and additional services.Patients who are working with providers to address thyroid or hormone issues will be expected to have bloodwork done followed by an appt to review the results every 6 months. There will be no exceptions to this policy. All appointments and services are at an additional charge. After the 2nd Visit, subsequent visits typically range from 15 minutes at $210 to 30 minutes at $375. Prices are subject to change without notice. For questions about the cost for our services, please ask! Our receptionists will be happy to review pricing with you upon request.

Reschedule / Cancellation Policy: You may reschedule your New Patient appointment, one time only, if we are notified within 3 business days. If less than 3 days, the balance of $300 ($600 less $300 deposit) must be paid in full at the time you reschedule your appointment. To reschedule your appointment, please leave us a message at 248-851-1600 Ext 222 or email us at info@centerforholisticmedicine.com. There are no refunds for New Patient appointments that are missed or cancelled. Please note that the $300 deposit is non-transferrable.

Missed Appointments: If you do not show up for your New Patient Appointment and wish to schedule again, you will be required to pay a full deposit of $600 in advance. Note that this deposit is non-refundable & non-transferrable.

Out of State Patients: To ensure the best quality of care, all out of state patients are required to be physically seen at our office on a yearly basis, as determined by your CHM healthcare professional. If this requirement is not met, you will lose your status as a current patient at CHM. Please note that there will be no exceptions made to this policy.
I have read and agree to the terms & conditions of the New Patient Policies that I read in the New Patient Guide, at the Center for Holistic Medicine.
Patient | Parent | Guardian Signature*

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Pharmacy Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Name of Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.

Private Contract for Medical Treatment | MEDICARE WAIVER

Please fill out this form if you're of Medicare age, regardless if you use Medicare or not.
This contract is being entered into by and between David Brownstein MD, Richard Ng MD, Jeffrey Nusbaum MD, Cynthia Lepake MD, Hailey Brownstein DO, Jessica Brownstein DO, and/or Jessica Gross PA-C (the “Physician Assistant”) who has not been excluded from Medicare under the Social Security Act and {name} (the “Patient”), who is a Medicare beneficiary. The Patient agrees to the following:
1. I will not submit a claim or request that Dr. D. Brownstein, Dr. Ng, Dr. Nusbaum, Dr. Lepak, Dr. H. Brownstein, Dr. J. Brownstein, or Jessica Gross, PA-C submit a claim to Medicare for such items or services used or employed by Dr. D. Brownstein, Dr. Ng, Dr. Nusbaum, Dr. Lepak, Dr. H. Brownstein, Dr. J. Brownstein, or Jessica Gross, PA-C in his/their treatment, even if such items or services are otherwise covered by Medicare.
2. I or my legal representative agree to be responsible for payment of such items or services used or employed by Dr. D. Brownstein, Dr. Ng, Dr. Nusbaum, Dr. Lepak, Dr. H. Brownstein, Dr. J. Brownstein, or Jessica Gross, PA-C in his/their treatment and further understand that no reimbursement will be provided by Medicare.
3. I acknowledge that no Medicare limits apply to amounts that may be charred for any items or services used or employed by Dr. D. Brownstein, Dr. Ng, Dr. Nusbaum, Dr. Lepak, Dr. H. Brownstein, Dr. J. Brownstein, or Jessica Gross, PA-C in his/their treatment.
4. I acknowledge that Medigap plans do not, and other supplemental insurance plans may elect not to may payments for such items and services used or employed by Dr. D. Brownstein, Dr. Ng, Dr. Nusbaum, Dr. Lepak, Dr. H. Brownstein, Dr. J. Brownstein, or Jessica Gross, PA-C in his/their treatment, because payment is not being made by Medicare.
5. I acknowledge that as aMedicare beneficiary, I have the right to have such items or services provided by other practitioners for which payment may be made by Medicare. In addition, the beneficiary is not compelled to enter into private contracts with other physicians/practitioners who have not opted out of Medicare
6. I acknowledge that this contract is null and void during a time when I may require emergency or urgent care services.
7. I acknowledge that this contract will be valid for the opt out period beginning January 1st, 2024 through December 31st, 2025
Patient | Guardian Signature

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Drivers License & Insurance Card

Please upload a photo of your drivers license/state ID and any insurance card information. You can also skip this step and provide physical cards during check-in prior to your appointment.
Driver's License Front

Cancelof
Drivers License Back

Cancelof
Insurance Card Front

Cancelof
Insurance Card Back

Cancelof
Secondary Insurance Front

Cancelof
Secondary Insurance Back

Cancelof
Should be Empty:

Patient Forms

Patient Information

General Consent Form

Financial Policy

Request for Treatment

Consent to Share Information

New Patient Guide Acknowledgement

Pharmacy Information

Private Contract for Medical Treatment | MEDICARE WAIVER

Drivers License & Insurance Card

CENTER FOR HOLISTIC MEDICINE, PLLC