New Patient Form

COVID-19 SCREENING FORM

Patient/visitor has a fever (?100.4 visitor/patient>100.0HCP) AND signs / symptoms of lower respiratory illness (e.g. cough or shortness of breath)

Patient/visitor has had close contact with a laboratory confirmed COVID-19 patient within the last 14 days

Patient/visitor has a fever(?100.4 visitor/patient>100.0 HCP) OR signs /symptoms of lower respiratory illness AND a history of travel from affected geographic regions within 14 days of symptom onset

Patient/visitor does not meet any of the above criteria

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.

Name

Phone

Appointment Date

WELCOME TO OUR PRACTICE

Today's Date

Patient Information

First Name

Last Name

Middle

Date of Birth

Social Security No.

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email address

Referred By

INSURANCE INFORMATION

Primary Insurance

Identification No.

Group No.

Primary Insurance Address

Secondary Insurance

Identification No.

Group No.

INSURED'S INFORMATION

Employer of Insured

Policy Holder's Name (If other than self)

Last Name

First Name

DOB of Policy Holder

Address

City

State

Zip Code

Home Number

Work Number

Cell Number

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.

Signature on File

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

Date

Patient History

Last Name

First Name

Height

Weight

Blood Pressure

Date of Birth

Primary care physician

Name

Phone Number

(XXX-XXX-XXXX)

Address

MEDICAL HISTORY

Anxiety

Yes No

Arthritis

Yes No

Asthma

Yes No

Cancer

Yes No

CHF

Yes No

Diabetes Non‐Insulin

Yes No

Diabetes Insulin

Yes No

GI Ulcers

Yes No

GI Reflux

Yes No

Heart Attack / MI

Yes No

Heart Disease

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Hyperthyroid

Yes No

Hypothyroid

Yes No

Kidney Disease

Yes No

Low Blood Pressure

Yes No

Liver Disease

Yes No

Murmur

Yes No

Vascular Disease

Yes No

If other, Please specify

SURGERY

If yes, what year?

Other

SOCIAL HISTORY

FAMILY HISTORY

If other, please specify

Add Additional Medications

Drug Allergies

Chief complaint is

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.

Patient Signature (if minor, parents)

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

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, MASTERCARD/VISA, VENMO, OR ZELLE

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, VISA, Venmo, or Zelle 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.

How will you be paying today? - **3.99 % fee will be added for all credit cards

Check

Cash

Visa

MasterCard

Venmo

Zelle

Credit Card #:

Expiration Date:

CSV:

Add new row

I GIVE AUTHORIZATION TO TEXT OR EMAIL BILLS

Yes No

Signature of Patient or Responsible Party

Date

Dr. Hagen and Grossman - HIPPA INFORMATION AND CONSENT FORM

The health insurance affordability and accountability act (HIPPA) provides safeguards to protect your privacy. Implementation of HIPPA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPPA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the US Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care re handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain and coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as front office, exam rooms, etc. These records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents.
It is the policy of this office to remind patients of their appointments. We may do this by telephone, email or text or any other means convenient to the practice. We may send you other communications informing you of changes in office policy and new technology that you may find valuable or informative.
The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to confidentiality rules of HIPPA.
You understand and agree to inspections of the office and review of the documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for purposes of marketing or advertising of products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Date

do hereby consent and acknowledge my agreement to the terms set forth in the HIPPA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Your information will be encrypted.

New Patient Form

COVID-19 SCREENING FORM

Patients:

WELCOME TO OUR PRACTICE

Patient History

MEDICAL HISTORY

SURGERY

SOCIAL HISTORY

FAMILY HISTORY

FINANCIAL POLICY

REGARDING INSURANCE

Dr. Hagen and Grossman - HIPPA INFORMATION AND CONSENT FORM

Dr. Jill Hagen & Dr. Lauren Grossman

Podiatrists