Patient Intake Forms

Foot and Ankle - Institute of Colorado

Please correct the errors described below.

PATIENT INFORMATION

Person Responsible for the Account (If different from above)

INSURANCE INFORMATION

*WE NEED DATE OF LAST VISIT FOR MEDICARE TO PROCESS CLAIMS

HEALTH HISTORY

Tobacco

I acknowledge that I was offered or provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understood the Notice. Also, may we leave phone messages regarding your Protected Health Information with the following:

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.

OFFICE POLICIES

Photo Identification

We require that each patient present a photo ID issued by a local, state or federal government agency (drivers license, passport, military ID, etc). The request is to protect against identity theft for medical services.

Minor patient authorization

All minors are required to have a parent or guardian present for each appointment. By law, we are required to have a consent for treatment from a legal guardian to provide treatment to a minor.

Insurance information

Please provide us with your insurance card(s), referral and worker's compensation information upon registration at the front desk. If further information is requested, please fax the requested documents to us at (719) 488-4667 within 24 hours.

PAYMENT POLICIES

Method of Payment

We accept the following forms of payment: cash, personal and bank checks, Visa, Mastercard, Discover and American Express credit or debit cards. All returned checks will have a $30.00 return check fee in addition to the full amount of the original check.

Surgery Patients

We will authorize your insurance for surgery. It is the patient’s responsibility to check their insurance for coverage and to know their policy before surgery.

Patients Without Insurance Coverage

Payment for medical services and dispensed items are due at the time of service. We are pleased to provide an estimate of costs for services and offer a 30% discount for medical services provided on your visit and will outline a cost plan for future services.

Patients with Insurance Coverage

Your insurance is a contract between you and your insurance company. While we cannot guarantee that your insurance company will pay your claim, we will provide information to them if requested and the above data is accurate and complete. I understand that I am responsible for any CO-PAYMENTS, DEDUCTIBLES OR BALANCES not covered by my insurance.

COLLECTION POLICY

In the event our office is not contacted within 30 days of you receiving our last billing statement, your account will be turned over to our collection agency. Any collection fees, court costs, reasonable attorney fees or returned check fees are the responsibility of the adult person(s) named on the account. A monthly service fee of 1.5% per month or 18% per annum will be assessed on all past due accounts.

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.

Insurance Authorization and Assignment of Benefits

I hereby authorize treatment of the above patient or minor patient. I hereby authorize Foot and Ankle Institute of Colorado, P.C. to furnish information to insurance carriers regarding my illness and treatments and I hereby assign to the physician(s) all payments for medical services rendered for myself and my dependents 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 Right of Access Form for Family Member/Friend

I (enter your name above),direct my health care and medical services providers and payers to disclose and release my protected health information described below to:

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(NOTE: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.)

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.

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