New Patient Information

Patient's Last Name

Patient's First Name

Middle Initial

Social Security #

COMPLETE # REQUIRED FOR MILITARY INSURANCES

Date of Birth

Physical Address (NO PO BOXES)

Zip Code

Billing/Mailing Address

Zip Code

Contact Phone #

Email address

Employer's Name and Address

Business Phone

Referring Physician

Primary Care Physician

Preferred Language (Optional)

Ethnicity (Optional)

Emergency Contact Name

Relation

Emergency Contact Phone Number

IF PATIENT IS A CHILD, PLEASE COMPLETE THE FOLLOWING:

Parent/Guardian Name

Relationship to Patient

Home Phone

Cell Phone

Business Phone

Child's School

Child's Grade

Other Person(s) Who may authorize treatment for child and Relationship

INSURANCE INFORMATION

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***PLEASE PROVIDE CARDS AT THE APPOINTMENT IF NOT UPLOADED, AND INFORM A STAFF MEMBER IF YOU HAVE MORE THAN 2 INSURANCE COVERAGES.***

AUTHORIZATION TO RELEASE MEDICAL INFORMATION and ASSIGNMENT OF INSURANCE BENEFITS: I authorize Gregory B. Morris, DPM, LLC, or its representative, to release to my insurance company or its representative any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such medical or surgical care. I hereby authorize that payments for these services be made directly to my physician or supplier.

FINANCIAL AGREEMENT: I understand that I am financially responsible for all charges whether or not paid by said insurance. These include deductible, co-payment, cost-share, and/or non-covered benefits. I also agree to pay a late payment fee of 1% a month on any unpaid balance over 90 days old together with reasonable attorney's fees and collection expensive should the account be referred to an attorney or collection agency. I agree to pay a $10.00 processing fee for each returned check.

I certify that the insurance information I have provided is correct. I permit a copy of this authorization to be used in place of the original. This authorization is valid until revoked by me in writing.

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.

Patient/Parent/Guardian Signature

Relationship to Patient

Date

INJURY / PROBLEM HISTORY

Please indicate on the diagram and in a few brief words, what is your foot or ankle problem?

When did this problem begin and what treatment has been done for it?

If Yes, when did you last see your physician?

If Yes, Indicate Date of Injury:

Claim # (If Known)

Liability Insurance Company and Adjuster's Name

MEDICARE PATIENTS ONLY, PLEASE READ AND SIGN BELOW

Dear Patient: Medicare regulations suggest that I, Dr. Gregory Morris, inform you in advance, that some medical services may not be fully covered or reimbursed by Medicare. If in my professional opinion and judgment, the following services are needed in order to provide to you with the highest quality of care, they may not be completely reimbursed by Medicare:

Routine foot care and medical appliances.
Medicare may not reimburse these services for the following reasons: Non-Covered service.

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.

MEDICARE Patient's Signature

Date

MEDICAL HISTORY AND QUESTIONNAIRE

Primary Care Physician Name

Date Last Seen

Other: (Please specify)

If yes, Please mark which days:

MON

TUE

WED

THUR

FRI

SAT

FAMILY MEDICAL HISTORY

If Deceased, Please specify cause

Siblings - (If Deceased, Please specify)

Smoking Status (You may check more than one):

Current Everyday

Current Someday

Former Smoker

Heavy Smoker

Light Tobacco

Chew Tobacco

ECIG

Never Smoked

If former smoker, When did you quit?

PLEASE LIST ALL MEDICATIONS / VITAMINS AND DIRECTIONS:

Please list all previous SURGERIES Name & Specify Body Part:

I understand that my signature is on file authorizing release of my medical records or any other information required to process insurance forms. I also request payment of medical benefits to Gregory Morris, DPM, FACFAS. I give my permission to physicians to administer treatment and to perform such procedures as may be deemed to the diagnosis and / or treatment of my foot / or ankle conditions.

Signature of Patient/ Parent/ Guardian:

Date

EPRESCRIPTION DISCLOSURE:

Gregory B. Morris, DPM, FACFAS, LLC is in the process of implementing ePrescribing in our office.

ePrescribing is a federally mandated initiative that requires all physicians to prescribe in this manner by 2011.

ePrescribing software sends prescriptions over the internet to your pharmacy in a safe, secure way, through the same technology used by credit card companies. This helps protect the privacy of your personal information.

ePrescribing software also lets your doctor see important information - like drug interactions and your prescription history.

The benefit to you:

Less confusion over handwritten prescriptions or unclear phone calls
Reduced possibility of medical errors
Less chance of adverse drug reactions
Fewer trips to drop off at the pharmacy
A safer, faster, easier way to get your prescription filled

Patient Consent
I agree that Gregory B. Morris, DPM, F ACF AS, LLC may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes.

Email address

Signature of Patient

Date

Pharmacy Of Choice

Location

Acknowledgement of Receipt of Notice of Use And Disclosures Of Protected Health Information For GREGORY B. MORRIS, DPM, LLC

I have read the Notice of the Uses and Disclosures of Protected Health Information (the "Notice") that is posted in your office. I was informed that I may also obtain a printed copy of the Notice from your receptionist. I hereby acknowledge that I received from Gregory B. Morris, DPM, LLC a copy of the Notice.

Patient Name / Signature

Date

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