New Patient Form

Please correct the errors described below.

COVID-19 SCREENING FORM

Patients:

If any of the first three boxes are checked, the patient should not enter this building and should call their primary care doctor immediately.

FINANCIAL POLICY

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our FINANCIAL POLICY which we require you to read and sign prior to initial treatment.

  • ALL PATIENTS MUST COMPLETE OUR INFORMATION AND INSURANCE FORM BEFORE SEEING THE DOCTOR.
  • WE ACCEPT CASH, CHECKS OR MASTERCARD/VISA.

REGARDING INSURANCE

Your insurance policy is a contract between you and your insurance company. We are not a part of that contract. Please be aware that some of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare program and other medical insurance programs. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. You are responsible for all non-covered services, deductibles, copays, and coinsurance.

ADULT PATIENTS AND MINOR PATIENTS: Adult patients (18 or older) are responsible for payment.

The adult accompanying the minor and the parents (or guardian of the minor) are responsible for payment. For unaccompanied minors, non-emergency treatment will be denied unless payment by Cash, Check, MASTERCARD or VISA at the time of service has been verified.

PATIENT LIABILITY: If this account is assigned to an attorney for collection and/or suit, I shall pay 33 1/3% of the claim as payment for attorney's fees and cost of collection.

CHECK RETURN POLICY: For any check that is returned from the bank there will be a service charge of $30.00 that must be paid to Podiatry Associates.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.

I HAVE READ THE FINANCIAL POLICY. I UNDERSTAND AND AGREE TO THIS FINANCIAL POLICY.

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.

Patient History

MEDICAL HISTORY

SURGERY

SOCIAL HISTORY

FAMILY HISTORY

Add Additional Medications

I hereby give permission to Dr. Jill Hagen, DPM / Dr. Lauren Grossman, DPM and/or associates for the examination and rendering care for my foot problem and/or related condition.

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.

WELCOME TO OUR PRACTICE

Patient Information

INSURANCE INFORMATION

INSURED'S INFORMATION

Insured's Name (If other than self)

If other than the above, please discuss payment with the office receptionist.

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.

(Authorization to file claims / release insurance information / appeal claims / charge balances on credit card on file)

Your information will be encrypted.

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