New Patient Paperwork Form

Patient

Name

SSN

Date of Birth

Address

City

Zip

Home Phone

Cell Phone

Are you being seen for a Workman’s compensation or a Auto Accident injury?

Yes No

Marital Status

M S D W

Language Preference

English

Spanish

Other

If other, please indicate

Race

American Indian or Alaska Native Asian Black or African American native Hawaiian or Other Pacific Islander White

Ethnicity

Non Hispanic or Latino Hispanic or Latino

Employer

Position

Primary Care Physician

Last time seen by PCP

Pharmacy you use

Do you have the Oregon Health Plan

Yes No

How did you hear about us?

Internet

Friend

PCP

Hospital

Upload copy of their insurance card

Add file

Please upload a file

Responsible Party ( If other than patient)

Name

Relation to Patient

Date of Birth

Sex

M F

Social Security Number

Employer

Work Phone

Emergency Contact Information

Name

Relation to Patient

Phone Number

Contact Preference for appointment reminders: (Initials by all approved)

Patient

Spouse

Anyone answering the phone

Other

If other, please indicate

Federal Government Requirements

Have you had your Flu shot this season (Oct 1st - March 31st)

Yes No

Have you ever had a Pheumococcal Vaccination in your lifetime?

Yes No

Notice of Patient Privacy Practices (HIPAA)

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand my health information can and will be used to (1) conduct, plan and direct my treatment and follow up among multiple healthcare providers who may be involved in that treatment directly and indirectly. (2) Obtain payment form third-party payers. (3) Conduct normal healthcare operations such as quality assessments and physician certifications. I know that I can request a copy of the Notice of Privacy Practices which contains a more complete description of the uses of disclosures of my health information from Cascade Foot Center at anytime. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact Cascade Foot Center at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Cascade Foot Center restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I understand that Cascade Foot Center is not required to agree to my restrictions but if it does agree, then it is bound to abide by such restrictions. I permit Cascade Foot Center to communicate test results, doctor's instructions, and appointment reminders in the above marked manner.

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.

Patient or Responsible Party Signature

Date

Medical History

Describe your current foot problem?

Past foot or ankle surgeries

How many hours do you spend on your feet each day?

0-1 2-4 5-8 9-12 over 12

Do you drink alcohol?

Yes No

If yes, please specify if

Daily Weekly Monthly

Do you use tobacco or nicotine products?

Never Current everyday user Current someday user Former

Do you use Recreational Drugs?

Yes No

Family History

Diabetes

Mother Father

Heart Disease

Mother Father

Foot Problems

Mother Father

Blood Disorders

Mother Father

Surgical History

Do you have a history of trouble with anesthesia?

Yes No

If yes, explain

Cardiac Sugeries

Yes No

Do you heart valve troubles?

Yes No

Artificial heart valve?

Yes No

Do you have a pacemaker?

Yes No

Do you have any stents?

Yes No

Orthopedic Surgeries

Yes No

If yes, which joints?

List major surgeries in the last 10 years

List medications you take on a regular basis (or attach a list)

File attachments

Add file

Please upload a file

Do you have allergies to any medications, Latex, or Iodine?

Yes No

If yes, which ones

If cancer, please specify

If gout, please specify

If Other, please specify

Height

Weight

Shoe Size

Billing/Account Policy

(Please read the following carefully and ask questions before signing)

Patient Financial Responsibility. You are financially responsible for payment of your medical care at Cascade Foot Center. If you are uncertain whether your services or products are covered by your insurance plan, you should confirm this with your insurance carrier prior to your appointment. You are responsible to obtain referral and/or authorizations for your services as may be required by your policy. Our office is not responsible to obtain referral and/or authorizations for your services as may be required by your policy. Our office is not responsible for charges denied because a referral was not obtained before services were rendered. Co-payments are due at the time of your appointment. When we are have complete billing information, we are able to bill most insurance companies directly for you. You are responsible for deductibles, copayments, and services or products not covered by your insurance carrier. If you have a balance owing to us, the balance is due within 45 days of the date of our first statement. If you are unable to pay within 45 days, you must contact our Accounts Department to establish a payment plan to ensure no further action will be taken on your account. Your first two monthly statements will be sent to you free of charge. After that time, each billing statement issued will incur a $4.00 statement fee until your account is paid in full. If you do not have insurance coverage, we currently offer our patients a 10% discount off our regular fee schedule. Payment of your bill is DUE AT TIME OF SERVICE. If you have a high deductible a $100 payment is due at the time of service. There will be a $25.00 fee for any check returned by your bank for non-sufficient funds. Any established patient who fails to show or cancels/reschedule an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $25.00 Fee. Any established patient who fails to show or cancels / reschedule an appointment with no 24 hour notice a second time will be charged a $50 fee. If a third No Show or cancellation / reschedule with no 24 hour notice should occur the patient may be dismissed from Cascade Foot Center. The fee is charged to the patient, not the insurance company, and is due before we are able to schedule your next appointment. If we are required to turn over your account for collections, in addition to your account balance, you agree to pay any and all collections fees whether litigations is commenced or not, including attorney fees. I understand and agree to the terms of Cascade Foot Center Billing Policy.

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.

Patient/Responsible Party Signature

Date

Your information will be encrypted.