New Patient Registration Form

Patient Information

Primary Insurance

Family Medical History

Social History

Authorization

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the doctor to help determine appropriate treatment. If there is any change in my medical status, I will inform the doctor. I give permission to John Patton, Ltd. to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my lower extremities.

I authorize my insurance company to pay to the doctor or medical group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

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.

Payment or co-pay is due in full at time of treatment, unless prior arrangements have been approved.

HIPAA POLICY AND PRIVACY PRACTICES

Your protected health information may be used and disclosed by your physician/office staff and others outside our office (i.e billing office) for the purpose of providing health care services to you.

We will disclose your health information to provide, coordinate or manage your health care. For example, your health care information will be disclosed to a physician to whom you have been referred for treatment or continuation of care.

Payment- Your health information will be used, as needed to obtain payment for services rendered. For example, but not limited to, your insurance carrier may require office notes from dates of service to determine payment.

We may use or disclose your protected health information without your authorization in the following situations: As required by law for communicable diseases, abuse or neglect, legal proceedings, law enforcement, coroners, funeral directors or organ donation.

You have the following rights under the Privacy Rule: Right to Access your PHI (PRIVATE HEALTH INFORMATION), Right to request amendment of PHI, Right of accounting of disclosures, Right to request restrictions of PHI, Right to request confidential communications, and Right to complain about privacy rule violations.

Notification Authorization

I give permission to Dr. John Patton and/or employees to notify me about my healthcare including, but not limited to test results, treatment plans, appointments, prescriptions, and account information with the following people.

PATIENT FINANCIAL POLICY

Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor.

• As our patient you are responsible for all authorizations/referrals needed to seek treatment in this office.
• Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, cash or check.
• Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.
• We have made prior arrangements with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/co- insurance/deductible at the time of service.
• If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service.
• All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.
• You must inform the office of all-insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied.
• For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.
• There are certain elective surgical procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.
• Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office.
• If your account is transferred to a collection agency, John Patton, Ltd. will assess a collection fee equal to the amount of 30% of the outstanding balance.
• There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee.

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.