● FORMULARY v2026.05.06／ NEXT REVISION 2026-08-04／ ● CCH-001 OPEN／ ● CCH-002 OPEN · 3 SLOTS／ ● CCH-003 WAITLIST 11d／ ● CCH-004 OPEN／ ● CCH-005 OPEN／ ● CCH-006 LIMITED／ ERRATA: 14 ENTRIES SINCE 2024-Q2／ BEGIN INTAKE OPEN ⟶／ ● FORMULARY v2026.05.06／ NEXT REVISION 2026-08-04／ ● CCH-001 OPEN／ ● CCH-002 OPEN · 3 SLOTS／ ● CCH-003 WAITLIST 11d／ ● CCH-004 OPEN／ ● CCH-005 OPEN／ ● CCH-006 LIMITED／ ERRATA: 14 ENTRIES SINCE 2024-Q2／ BEGIN INTAKE OPEN ⟶／
Pharos · Kingston NY
Begin · intake form · v2026.05

The intake is three pages.
The first visit is sixty minutes.

If you'd like to be seen, fill out the form below. We will run a benefits check, request your prior records on your behalf, and offer a new-patient appointment within 10 business days for adult primary care, 3–6 business days for pediatrics, and 11 business days for behavioral health (current waitlist).

Privacy
We follow the HIPAA Privacy Rule and our privacy notice.
Records request
We initiate it for you on submission.
Form length
≈ 8 minutes
After submission
Maritza calls within 1 business day

The form below is a representation. We use a HIPAA-aligned tool for the actual submission; the live link is sent to you when you call the front desk at (845) 555-0142 or email front@pharos-kingston.example.

Page 1 — About you
Page 2 — Insurance
If you are uninsured That is fine. The DPC membership pathway is described in the membership page; cash sliding-scale rates are also available.
Page 3 — Health history

Please name your prior practice and PCP, if any. We will send the release form for your signature; we initiate the records request on your behalf.

Visit details

By submitting, you agree to our privacy notice, including the records-release authorization for the prior practice you have named. The form is for new-patient establishment only; if you are an established patient, please call the front desk for any clinical concern.

What happens after you submit

Maritza Polanco at the front desk will call you within one business day. The call covers: insurance benefits check, scheduling the new-patient visit, and any clarification needed on the intake form. The records request to your prior practice is initiated the same day on your verbal authorization.

If you are seeking CCH-003 care and our current waitlist is more than you can wait, Maritza will work with you on a referral to one of the Hudson Valley behavioral health practices we know well; we maintain a small list at the front desk that we trust to refer to.

Things we will not ask on the intake form

We do not ask: how you would rate your last clinic on a five-star scale; whether you have a "primary goal" beyond the clinical reason you are coming in; whether you would like to opt into marketing emails. The form does not have those fields because we believe the form should be a clinical document, not a marketing one.

If the form does not work for you

You can call the front desk and complete the same questions on the phone. The form is not the only path. The phone is, in fact, the older path; we still answer it.