New Patient Form

PODIATRIC COMPLAINTS

MEDICATIONS

Please list all prescriptions, over-the-counter medications, and vitamins you are currently taking. Give us a list if you have one:

Please list any allergies:

FAMILY HEALTH HISTORY

If you answered yes, we will need the accident information from your employer.

SURGERIES

PRIMARY PHYSICIAN

*DIABETIC PATIENTS: If you are on Medicare (or an equivalent), we need the EXACT DATE of your last doctor visit. Medicare requires that you have seen your Primary Doctor in the past 6 months in order to see a Podiatrist

IN CASE OF EMERGENCY, CONTACT

INSURANCE

PLEASE BRING INSURANCE CARDS TO YOUR APPOINTMENT AND PRESENT INSURANCE CARDS FOR PHOTO COPYING

We bill Medicare, or one of its equivalents, and if your secondary insurance company has a contract with Medicare we put the secondary insurance information on the Medicare insurance claim form. This is known as “Medigap” or “Cross Over Claims”. Medicare then sends the information to your secondary insurance directly. If your secondary insurance does NOT have a contract with Medicare for “Medigap” or “Cross Over Claims” you will need to make a copy of your Medicare explanation of benefits, include your secondary insurance information and mail to your secondary insurance company. We do not submit claims to the secondary insurance companies.

INSURANCE AUTHORIZATION

I request that payment of authorized insurance benefits be made either to me or on my behalf to Dr. Bradley G. Burkart for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other” health insurance is indicated in item 9 of the HCFA-1500 firm or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.