Pain Management Yorktown Heights

Patient Resources

Patient Forms

The following forms will need to be completed prior to your first visit at Hudson Valley Pain Management.  In order to save time during the registration process, please print, complete and bring the attached forms to your initial visit.

Accepted Insurance Plans

We currently accept the following insurance plans
  • Aetna
  • Blue Cross Blue Shield
  • Beech Street
  • CHN
  • Cigna
  • Corvel
  • Coventry National
  • First Health
  • Great West
  • Magnacare
  • Medicare
  • Medicaid
  • Multiplan
  • MVP
  • NHAI
  • Oxford
  • Tricare
  • UHC
  • UHC EP
  • Workers com- NY state
  • Workers comp- Federal

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Patient Policies


 All co-payments are due at the time of your appointment.

Methods of Payment

We accept cash, check, and credit card (Visa, MasterCard, American Express, and Discover Card)

Cancellations/ Delays

Please arrive 15 minutes prior to your scheduled appointment time.

Please notify the office if you are running late.  Patients arriving more than 10 minutes after their scheduled time may be asked to reschedule.

We require at least 24 hours notice for all cancellations.  Your account will be assessed a $50 fee for missing an appointment without prior notice.


Notice of Health Information Practices Summary

Your Medical Record 
Each time you visit a hospital or physician, a record is made of your visit.  This information, commonly known as a medical record, contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care.  The confidentiality of your medical record is protected under the State-specific and Federal law.

Your Health Information Rights 
Your medical record is the physical property of the physician or healthcare facility that compiled it, but the information belongs to you.  Therefore, you have rights regarding the use and disclosure of your health information.

Our Responsibilities 
Hudson Valley Pain Management is required by the Federal Privacy Rule to maintain the privacy of your medical record and to provide you with a notice of our legal duties and privacy practices.

Uses and Disclosures for Treatment, Payment, and Health Care Operations 
Hudson Valley Pain Management will use your health information in order to treat you.  We will provide other providers or hospitals with copies of your medical record to assist them in treating you, should that become necessary.  We will also use and disclose health information about you to make appointments with you.

Hudson Valley Pain Management will use your health information for payment.  The information on a bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Hudson Valley Pain Management will use your health information for regular health operations to assess the quality of your care.
Hudson Valley Pain Management will disclose your health information to business associates, such as a medical transcription or billing service; so that they can perform the job we have asked them to do.

Uses and Disclosures that We May Make Unless You Object
You have the right to object to certain situations in which Hudson Valley Pain Management may disclose information from you medical record.

Disclosures Permitted without Consent 
Hudson Valley Pain Management is required by state and Federal law to disclose health information from your medical record under specific circumstances.

Uses and Disclosures Specifically Authorized by You
Hudson Valley Pain Management expects to make other uses and disclosures of your protected health information only on the basis of specific written authorization forms signed by you.

To Report a Problem
You have the right, under Federal law, to report a problem or file a complaint about how your personal health information is being handled.  You can do this directly with Hudson Valley Pain Management or to the Secretary of Health and Human Services in Washington, D.C.

Hudson Valley Pain Management will use and disclose your personal health information to treat you, to receive payment for the care we provide, and for other health care operations.  Health care operations generally include those activities we perform to improve the quality of care.

We have prepared a detailed Notice of Privacy Practice to help you better understand our policies in regards to your personal health information.  The terms of the notice may change with time and we will always post the current notice at our office and have copies available for distribution.

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Helpful Links

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