ALL Required Forms

Foot Health Center L.L.C

Please correct the errors described below.



    Please upload a file


    Policy Holder Information (if different from patient):


    Policy Holder Information (if different from patient):

    If financially responsible party has different mailing address, please indicate:


    I understand that the staff and /or physicians of Foot Health Center, LLC may need to contact me regarding appointments, test results or other issues related to my health. Listed below are my preferences:


    I AUTHORIZE THE STAFF AND/OR PHYSICIANS OF FOOT HEALTH CARE, LLC TO DISCUSS MY HEALTH CARE INFORMATION WITH THE INDIVIDUALS LISTED BELOW. I understand that I am not required to list anyone. I also understand that I may change the list in writing anytime

    Add another authorized person


    I authorize Foot Health Center, LLC to view my external prescription history via electronic prescribing services. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, pharmacies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years, and may include prescriptions to treat HIV, substance abuse and psychiatric conditions, if applicable. I understand that my prescription history will become part of my Foot Health Center, LLC medical record. My signature below certifies that I authorize the access to my prescription records.

    I hereby authorize and consent to the taking of photographs and moving pictures of me by Foot Health Center, LLC, its agents or employees. I hereby authorize and consent to the use of such photographs and moving pictures for identification purposes in my medical record. I hereby release Foot Health Center, LLC its medical staff, agents, and employees from all liability related to the making and use of such photographs and moving pictures for the purpose stated above


    I directly assign all health insurance benefits, to which I am entitled, by Medicare, Medicaid, Blue Cross, or any other insurance plans, directly to the providers of Foot Health Center, LLC for services rendered on my behalf. I understand that I am financially responsible for all charges, whether or not I am insured at the time of service, including deductibles, coinsurance, co-payments and benefits services that are out of network, denied and/or not covered by my health insurance plan. I authorize Foot Health Center, LLC or any other holder of medical or other information about me to release to Medicare, Medicaid, Blue Cross, or any other insurance carriers or their authorized agents any information needed for this or a related claim.


    I, the undersigned, voluntarily consent to and authorize Foot Health Center, LLC through its physicians, employees, and/or agents, to provide such medical care and examinations, on a continuing basis, and to administer such routine diagnostic, radiological and/or therapeutic procedures, tests and treatments as are considered necessary or advisable, in my diagnosis, care, and treatment, in the judgment of my Foot Health Center, LLC physician(s), including, but not limited to, collecting and testing bodily fluids, and administration of pharmaceutical products. I acknowledge that no guarantees have been made to me about the results of any examination or treatment.


    • I acknowledge receipt of the Foot Health Center, LLC Financial Policy, and agree to all the terms and conditions contained therein.
    • I acknowledge receipt of the Notice of Privacy Practices, and agree to all the terms and conditions contained therein (unless I have opted out alone).
    • I agree to allow access to my electronic prescription records as described above.
    • I acknowledge receipt of Foot Health Center, LLC Electronic Mail (e-mail) Policy, and agree to all the terms and conditions contained therein.
    • I agree to the release and assignment of benefits as described above
    • I agree to treatment as described above
    • I have read this form, my questions have been answered, and I understand and agree to its content

    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.


    Please present primary and secondary insurance card(s) so we may make a copy, along with your driver’s license or valid photo identification. If you do not have your card, you will be responsible for services rendered at that time, due to the overwhelming number of addresses for each insurance company and the necessity of having your ID#. As well, if a referral is needed, you need to supply it at time of visit. Please take note this office will only submit to two insurances. If this is workers compensation, auto claim, or claims going to your lawyer, please supply that information on date of service. But please take note, you will ultimately be responsible for the bill. Please be aware it is your responsibility to be aware if your insurance does not cover benefits for podiatry services or a particular service or treatment (diagnosis/billing code), under your plan. We strongly suggest that you call your insurance so that you understand your benefits and coverage, and the insurance’s disclaimer that they DO NOT GUARANTEE PAYMENT, not even with an authorization. Some insurances are just administrators and actual coverage or if we are in network may be different. So please call your insurance on the back of the card under member services to verify if we are on your plan and what your benefits/coverage includes for services, treatments, and durable medical equipment if necessary. When you call insurance, please make note with whom you spoke and reference #, as we do, in case needed for appeals. But please be aware we will do all that is required for appeal on our behalf, but you may have to call and send written documentation to your insurance as well. If appeal is unsuccessful, you are ultimately responsible for any services or products. Please follow up with your insurance on any Coordination of Benefits (COB) so your claim is not denied in which you will receive a bill. I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY CLAIM(S) AND HEREBY ASSIGN FOOT HEALTH CENTER, LLC (DR. MICHAEL VERDI, DR. KIRSTEN DISCEPOLA, Dr. MERIHAN BOTROS, AND DR. DOUGLAS N. DELORENZO.) ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO SELF OR DEPENDENTS. I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR ALL OF THE CHARGES FOR ALL OF THE SERVICES AND/OR PRODUCTS RENDERED TO ME OR ANY MEMBER OF MY FAMILY. ALTHOUGH I HAVE REQUESTED THE DOCTOR TO BILL MY INSURANCE ON MY BEHALF, I CLEARLY UNDERSTAND THAT IF A BILL IS NOT PAID BY MY INSURANCE WITHIN A TIMELY MANNER, I AGREE TO MAKE ARRANGEMENTS FOR PROMPT PAYMENT TO FOOT HEALTH CENTER, LLC. I AGREE TO HAVE A VALID REFERRAL (IT IS THE POLICYHOLDER’S RESPONSIBILITY TO KNOW IF INSURANCE REQUIRES REFERRAL) FOR VISIT AND ANYTIME INSURANCE CHANGES. Please supply updated or new insurance cards as you receive them. PLEASE NOTE: IF YOU HAVE NO INSURANCE YOU WILL BE RESPONSIBLE FOR PAYMENT AT TIME OF SERVICES

    HIPAA Omnibus Notice of Privacy Practices

    This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your Protected Health Information (PHI) to carry out Treatment, Payment or Health Care Operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. Please review it carefully. We reserve the right to change this notice at any time and to make the revised or changed notice effective in the future. A copy of our current notice will always be posted in the waiting area. You may also obtain your own copy by accessing our website at or calling the Privacy Officer at 973-731-1266. Some examples of Protected Health Information include information about your past, present or future physical or mental health condition, genetic information, or information about your health care benefits under an insurance plan, each when combined with identifying information such as your name, address, social security number or phone number.


    There are some situations when we do not need your written authorization before using your health information or sharing it with others, including:


    We may use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. For example, your Protected Health Information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.


    Your Protected Health Information may be used, as needed, to obtain payment for your health care services after we have treated you. In some cases, we may share information about you with your health insurance company to determine whether it will cover your treatment.

    Healthcare Operation

    We may use or disclose, asneeded, your Protected Health Information in order to support the business activities of our practice, for example: quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities.

    Appointment Reminders and Health-related Benefits and Services

    We may use or disclose your Protected Health Information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your Protected Health Information for fundraising activities, we will provide you the choice to opt out of those activities. You may also choose to opt back in.

    Friends and Family Involved in Your Care:

    If you have not voiced an objection, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for your care, including following your death.

    Business Associate:

    We may disclose your health information to contractors, agents and other “business associates” who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, a billing company, an accounting firm, or a law firm that provides professional advice to us. Business associates are required by law to abide by the HIPAA regulations.

    Proof of Immunization

    We may disclose proof of immunization to a school about a student or prospective student of the school, as required by State or other law. Authorization (which may be oral) may be obtained from a parent, guardian, or other person acting in loco parentis, or by the adult or emancipated minor.

    Incidental Disclosures

    While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.

    Emergencies or Public Need

    We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you. We may use or disclose your Protected Health Information in the following situations without your authorization: as required by law, public health issues, communicable diseases, abuse, neglect or domestic violence, health oversight, lawsuits and disputes, law enforcement, to avert a serious and imminent threat to health or safety, national security and intelligence activities or protective services, military and veterans, inmates and correctional institutions, workers’ compensation, coroners, medical examiners and funeral directors, organ and tissue donation, and other required uses and disclosures. We may release some health information about you to your employer if you employer hires us to provide you with a physical exam and we discover that you have a work related injury or disease that your employer must know about in order to comply with employment laws. Under the law, we must also disclose your Protected Health Information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

    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.


    There are certain situations where we must obtain your written authorization before using your health information or sharing it, including:

    Most Uses of Psychotherapy Notes, when appropriate


    We may not disclose any of your health information for marketing purposes if our practice will receive direct or indirect financial payment not reasonably related to our practice’s cost of making the communication.

    Sale of Protected Health Information

    We will not sell your Protected Health Information to third parties.

    You may revoke the written authorization

    at any time, except when we have already relied upon it. To revoke a written authorization, please write to the Privacy Officer at our practice. You may also initiate the transfer of your records to another person by completing a written authorization form.


    Right to Inspect and Copy Records

    You have the right to inspect and obtain a copy of your health information, including medical and billing records. To inspect or obtain a copy of your health information, please submit your request in writing to the practice. We may charge a fee for the costs of copying, mailing or other supplies. If you would like an electronic copy of your health information, we will provide one to you as long as we can readily produce such information in the form requested. In some limited circumstances, we may deny the request. Under federal law, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information related to medical research where you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

    Right to Amend Records

    If you believe that the health information we have about you is incorrect or incomplete, you may request an amendment in writing. If we deny your request, we will provide a written notice that explains our reasons. You will have the right to have certain information related to your request included in your records.

    Right to an Accounting of Disclosures

    You have a right to request an “accounting of disclosures” every 12 months, except for disclosures made with the patient’s or personal representatives written authorization; for purposes of treatment, payment, healthcare operations; required by law, or six (6) years prior to the date of the request. To obtain a request form for an accounting of disclosures, please write to the Privacy Officer.

    Right to Receive Notification of a Breach

    You have the right to be notified within sixty (60) days of the discovery of a breach of your unsecured protected health information if there is more than a low probability the information has been compromised.

    Right to Request Restrictions

    You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, run our normal business operations or disclose information about you to family or friends involved in your care. Your request must state the specific restrictions requested and to whom you want the restriction to apply. Your physician is not required to agree to your request except if you request that the physician not disclose Protected Health Information to your health plan when you have paid in full out of pocket.

    Right to Request Confidential Communications.

    You have the right to request that we contact you about your medical matters in a more confidential way, such as calling you at work instead of at home. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests.

    Right to Have Someone Act on Your Behalf

    You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf.

    Right to Obtain a Copy of Notices

    If you are receiving this Notice electronically, you have the right to a paper copy of this Notice

    Right to File a Complaint

    If you believe your privacy rights have been violated by us, you may file a complaint with us by calling the Privacy Officer at 973-731-1266, or with the Secretary of the Department of Health and Human Services. We will not withhold treatment or take action against you for filing a complaint.

    Use and Disclosures Where Special Protections May Apply

    Some kinds of information, such as alcohol and substance abuse treatment, HIV-related, mental health, psychotherapy, and genetic information, are considered so sensitive that state or federal laws provide special protections for them. Therefore, some parts of this general Notice of Privacy Practices may not apply to these types of information. If you have questions or concerns about the ways these types of information may be used or disclosed, please speak with your health care provider.

    Foot Health Center,LLC

    Michael V. Verdi, DPM,FACFAS Danielle Acampora, DPM Kirsten Discepola, DPM Douglas N. DeLorenzo,DPM,FACFAS

    1500 Pleasant Valley Way Suite 204 West Orange, NJ 07052 973-731-1266 Fax 973-731-1712

    Health Insurance Portability and Accountability Act of 1996 HIPAA OMNIBUS NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised: March 25, 2013 Privacy Officer:Robin Verdi,RN,BSN By signing the Acknowledgement form you are only acknowledging that you received, or have been given the opportunity to receive, a copy of our Notice of Privacy Practices.


    Please list ALL medications you are taking (prescriptions and/or over the center)

    Add another medication



    Family History: List any diseases of parents, siblings, children or grandparents

    Add another family diease

    Review of Systems

    Michael V. Verdi, DPM Doug DeLorenzo, DPM Kirsten Discepola, DPM Merihan Botros, DPM

    Telephone Consumer Protection Act Prior Express Consent

    Foot Health Center, LLC 1500 Pleasant Valley Way, Suite 204 West Orange, NJ 07052 Phone: 973-731-1266 The Telephone Consumer Protection Act (TCPA) prohibits a person or company from kaing any call using any automatic telephone dialing system or an artifical or prerecorded voice to any wireless telephone number unless the call is made for an emergenc purposes or the call is made with the prior express consent of the called party.

    I agree to allow Foot Health Center, LLC to contact me regarding me regarding products or services related to my medical care. I understand that my medical care is not conditioned on my acceptance of this Prior Express Consent.

    Your message will be encrypted.