FOOT AND ANKLE CENTER OF THE CENTRAL COAST

PATIENT REGISTRATION

Date:

Patient’s Last Name:

Patient’s First Name:

Patient’s SSN#:

Patient’s DOB:

Age:

Shoe Size:

Sex:

M F

I request that all communications to me (via phone, mail or otherwise) by The Foot an Ankle Center of the Central Coast (Dr. Fillerup’s Office and/or his staff) be handled in the following manner:

Address for written communications:

City:

State:

Zip Code:

Billing Address (if different from above):

City:

State:

Zip Code:

Home Phone:

Work Phone:

Ext:

Cell Phone:

Where do you prefer to receive calls?

May we leave a message?

Occupation:

Employer:

Name of Pharmacy used:

Whom may we thank for referring you?

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

Signature of patient or authorized representative:

PATIENT MEDICAL HISTORY

If Other is selected, please specify:

Has any member of your family or close relative ever had?:

Heart Disease

Diabetes

Asthma

Cancer

Stroke

Please list any allergies to any medications?

Do you smoke?

Yrs.?

Current Medications:

Previous Surgeries:

Primary Care Doctor:

Last visit at Primary Care Doctor:

PODIATRIC HISTORY

If Other is selected, please specify:

INSURANCE INFORMATION

Primary Insurance

Insurance Company:

Subscriber’s Name:

Subscriber #:

Group #:

Copay:

Deductible:

Relationship to Insured:

Secondary Insurance

Insurance Company:

Subscriber’s Name:

Subscriber #:

Group #:

Copay:

Deductible:

Relationship to Insured:

AGREEMENT AND RELEASE

I, the undersigned, certify that I or my dependent have insurance coverage with (name of insurance company) and assign directly to Dr. Peter C. Fillerup all insurance benefits, if any, otherwise payable to me for services rendered.

Name of Insurance Company:

Payment/Copay is requested at the time of each visit. We except personal checks, VISA, MasterCard, cash and most insurance plans. It is extremely important that you bring your insurance cards to your appointment so that we may obtain the necessary and correct information to file claims for you.

It is difficult to know all the specifics about each insurance plan. It is your responsibility to obtain referrals and determine if we are a provider within your plan. However, complete payment is ultimately your responsibility.

HMO’S / PPO’S

It is necessary for you to check with your HMO and/or PPO for any special requirements. If you have an HMO and /or PPO that requires a referral from your Primary Care Physician (PCP), we ask that you call your PCP to verify that one has been done. We ask that you bring a copy of the referral to your appointment. If you arrive without this information you will be asked to reschedule your appointment until a referral has been completed.

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

Responsible Party Signature:

Relationship to Patient:

Date:

I hereby give permission to Dr. Peter C. Fillerup to administer treatment as agreed to be deemed necessary in the diagnosis and/or treatment of my Podiatric condition.

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

Responsible Party Signature:

Relationship to Patient:

Date:

I acknowledge that I was offered a copy of the Notice Of Privacy Practices, and that I have read (or had the opportunity to read if I so choose) and understand the notice:

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

Signature of Patient or authorized representative:

Date:

Updated Patient Registration Form

Name:

Date:

Address:

Apt:

City:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Primary Care Physician (PCP) Name:

Please Initial 1-8

1. We are required by your insurance to have an annual updated registration.

2. Although it is difficult to know all specifics about each insurance plan, it is your responsibility to know if we are a provider within your plan.

3. Payment/Copay/Deductibles/and Share-of-Cost are requested at the time of each visit. Please be aware of the amounts contracted with your inurance plan. You as the patient or guardian are responsible for all charges, regardless of insurance coverage.

4. If you have an HMO that requires a referral from your primary care physician, we ask that you call your PCP to verify that one has been done for each office visit.

5. Accounts sent to collections will not be reappointed to our office.

6. As of January 1, 2014 our office will be charging $35.00 for any missed appointments and $50.00 for missed laser appointments not cancelled within 24 hours.

7. Charges for medical forms are as follows: State Disability EDD Initial form - $25, Continuation form - $15, Employer form - $25, other Disability form $25, DMV form $10.

8. At this time we will not be accepting any Workman's Comp related injuries or insurance claims.

I hereby give authorization for payment of insurance benefits to be made directly to Dr. Fillerup. I hereby authorize this healthcare provider to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submission.

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

Patient or Responsible Party Signature:

Date:

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