Registration Form

Emergency Contact

Required for Reporting Purposes:

Responsible Party for Billing (if patient is a minor)

Primary Insurance

Secondary Insurance

Insurance Assignment and Release:

I authorize Carolina Foot Care, LLC to render necessary treatment to the above named patient. I authorize direct payment to Carolina Foot Care, LLC of any insurance benefits otherwise payable to, on, or behalf of the patient for all medical services. It is understood that I am financially responsible for the charges not covered by this assignment. Authorization is also given to release any and all medical information to the insurance companies involved to allow them to process any claims for all services rendered.

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.

Medical History Form

List and give year of all hospitalizations/surgeries:

Social History

Please tell us if you have any past or present use

Family History

Please tell us if any immediate family members have a history of the following:

Review of Systems

LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:

Prescription and over-the-counter medication (examples: aspirin, antacids) and herbals (example: ginseng, ginkgo). Include medications taken as needed (example: nitroglycerin).

Financial Policy of Carolina Foot Care, LLC

Please read all information and acknowledge by signing below.

1. We ask that you present your insurance card and picture ID at the time of your initial visit. It is your responsibility to provide us with the correct information to bill your insurance
2. If you have a change of name, address and/or telephone number, please notify the receptionist.
3. We will collect your deductible, co-payment, coinsurance, and/or non-covered services/supplies at the time of service. Each year, you will be expected to pay the allowed amount until your deductible is met. If you have a balance after your insurance(s) have paid, you will be expected to pay that amount. If your insurance denies all or part of our charge, you will be billed for that amount.
4. Patients with no insurance are expected to pay in full at the time of service.
5. If we do not participate with your insurance, we will file your claims as a courtesy. You will be expected to make payment in full at time of service.
6. We are participating providers with Medicare and will bill Medicare for all covered charges. If you have a secondary insurance (excluding Medicaid), we will file your secondary insurance.
7. We do not file Medicaid as primary or secondary. If you have Medicaid, you are expected to pay at the time of service.
8. You are expected to pay your balance in full within 30 days or call our billing department to establish a payment agreement. If you do not pay in a timely manner, your account may be referred to a collection agency and/or reported to the Credit Bureau. If you have been turned over to a collection agency and/or have a bad debt on your account, you must pay that amount in full before being seen.
9. We accept cash, check, Visa, and MasterCard.
10. There is a $30 returned check fee.
11. When an appointment is scheduled, time is specially allocated for you. We understand that there may be times when you are unable to keep an appointment, but ask the courtesy of a phone call to cancel your appointment. We prefer a 24 hour notice of cancellation.
12. Surgery Patients: As a courtesy, we will verify benefits before surgery. You will be responsible for your deductible, co-payment, coinsurance, and/or any outstanding balance on the day of your surgical consult.
13. Orthotics: As a courtesy, we will verify benefits for Orthotics. You will be responsible for your deductible, co-payment, coinsurance, on the day of your casting.

If you have questions regarding our financial policy, please contact our office manager at (864) 595-9300.

I have read the above and have a full understanding of the financial policy of Carolina Foot Care, LLC. I understand that whether or not I have insurance, I am ultimately responsible for the payment of charges.

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.

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice of Privacy Practices describes how we 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 controls your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that is related to your past, present or future physical or mental health or condition, and related health care services.

1. Uses and disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. And 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.

Payment:

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain the hospital admission.

Healthcare Operations:

We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, Public Health issues as required by law, Communicable Diseases, Health Oversight: Abuse or Neglect, Food and Drug Administration Requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Worker’s Compensation, Inmates, Required Uses and Disclosures, Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Sections 164.500.

Other Permitted and Required Uses and Disclosures

It will be made only with Your Consent, Authorization, or Opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indication in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information:

You have the right to inspect and copy your protected health information, Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact with your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before August 23, 2013.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgment that you have received this Notice of our Privacy Practices:

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.

If you selected any of the following choices above: