New Patient Packet

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PATIENT INFORMATION

PERSON RESPONSIBLE FOR BILL

NEAREST RELATIVE TO NOTIFY IN AN EMERGENCY NOT LIVING IN YOUR HOME

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Primary Insurance:

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I hereby assign, transfer, and set over to Jeff Grizzaffi, DPM all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand payment is expected at the time services are rendered. I understand that I am financially responsible for charges (co-pays, deductibles, co-insurances) whether or not they are covered by my insurance. I also understand I am financially responsible for charges incurred if insurance does not pay in a timely manner. I have read, understand, and agree to the above financial policy.

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

OFFICE POLICIES

1. Scheduled Appointments

We understand that delays can happen however we keep a very full busy schedule, so if a patient is 15 minutes past their scheduled appointment time, we may have to reschedule that appointment. The appointment will be rescheduled for the next availability or depending on our office schedule for the day, you may wait in office to be seen.

2. No Show Policy for Doctors Appointment

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. A fee could be assessed of $20 and this fee will not be covered by insurance and will need to be paid prior to another appointment being scheduled.

3. No Show Policy for Surgical Procedures

Due to the large block of time needed for surgical procedures in office, no shows may cause problems and added expenses for the office. If you no show for an in office surgical procedure there will be a $30 fee. This fee will not be covered by insurance and will need to be paid prior to another appointment being scheduled.

4. Account Balances

We will require that patients with self-pay balances must pay their account balances to zero (0) prior to receiving further services by our practice. Patients with account balances over $100 must make payment arrangements prior to appointments being made. Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to a business office representative with whom they can review their account and concerns.

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

(Office Use only)

MEDICAL INFORMATION RELEASE FORM

(HIPAA RELEASE FORM)

RELEASE OF INFORMATION

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This Release of information will remain in effect until terminated by me in writing.

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

MEDICAL INFORMATION

THIS INFORMATION IS IMPORTANT FOR OUR RECORDS AND YOUR HEALTH

HOW LONG HAS IT BEEN BOTHERING YOU? EXAMPLE: 2 DAYS, 4 WEEKS, 6 MONTHS, 2 YEARS

Check all that apply (provide Dr. Name treating conditions in capital letters)

Are you sensitive to:

SOCIAL HISTORY:

Mother:

Father:

Brother:

Sister:

CHECK ALL THAT APPLY:

REVIEW OF SYSTEMS:

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