New Patient Form

Please correct the errors described below.

*PLEASE HELP US GET TO KNOW YOU*

(List you PCP?) **Primary Care Doctor Name

Pharmacy Information

Protected health information (PHI) will only be released from our practice with a properly executed authorization from the patient or his/her personal representative, except for treatment, payment, or health care operations and as otherwise required by law. Examples of some instances in which are required to disclose your PHI include Public health activities; information regarding victims of abuse, neglect, or domestic violence; health oversight activities; judicial and administrative proceedings; law enforcement purposes, organ donations purposes, research purposes under certain circumstances; national security and intelligence; correctional institutions; and Worker's Compensation.

Womick Podiatry Clinic P.C. will only use or disclose PHI, except as noted above, consistent with the terms of the authorization.

A patient may revoke his authorization to use or disclose PHI at any time but actions taken prior to the revocation are excluded. If authorization is a condition of obtaining insurance coverage, and the authorization is revoked, the insurer may contest a claim under policy.

Authorization must be properly executed by the patient or his/her personal representative. It should include, the date signed, specific PHI to be released or used, to whom this use or release relates, and an expiration date for the authorization.

Disclaimer: 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.

Please list any personal representative whom information may be given to in case of an emergency or calling on your behalf.

*****(THIS SECTION IS FOR OFFICE USE ONLY)*****

Patient Information

Case of Emergency

Who do we contact?

Insurance

SEE ATTACHED/SCANNED INSURANCE CARD IN PATIENT CHART

***MUST BRING INSURANCE CARD TO EVERY APPOINTMENT AND IT WILL BE UPDATED EVERY 6 MONTHS OR IN THE EVENT OF NEW INSURANCE IN THE PATIENT CHART***

Insurance Assignment and Release

and assign directly to Dr. Debra A. Lee all Insurance Benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for the Medicare and Medicaid Services, Signature or Self, Beneficiary, Guardian or Personal Representative.

Disclaimer: 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.

Podiatric History

Parent Guarantor Agreement

  1. On my behalf, I hereby authorize treatment by Womick Podiatry Clinic P.C.
  2. I accept responsibility and guarantee payment for all services rendered to me, and upon default on any payment due to Womich Podiatry Clinic P.C. agree to pay all costs of Collections, including collection agency fees and attorney fees at 40%.
  3. If my check is returned, I will be responsible for the $35.00 returned fee for any reason.
  4. I understand and accept to pay all fees in full at the time of service if self-paying.
  5. I hereby authorize the release of any and all medical and/or charge information as is necessary for third-party reimbursement from Medicare, Anthem Blue Cross and Blue Shield, and/or any other agency involved in the payment of my treatment.
  6. The possibility exists (during treatment) for healthcare workers to become directly exposed to my blood or body fluids. In the event of such direct exposure, State Laws require a sample of blood to be tested for the presence of infectious diseases. The results of these tests will be released to me and my family and to the health care worker(s) who suffered the exposure.
  7. The assignment/obligations and authorization set forth in this statement and the insurance assignment shall be binding upon me both for the present treatment and that which may be rendered to me and my family in the future by Womick Podiatry Clinic.
  8. I authorize a copy of this medical record to be forwarded to my primary care Physician as well as any and attending or consulting practitioners.
  9. I also direct and assign payment from said third parties to Womick Podiatry Clinic, P.C. I understand that my insurance policy is a contact between me and my insurance company and that I am responsible to Womick Podiatry Clinic, P.C. for any charges not covered by insurance. If payment from my insurances is not received within 90 days, my account will become payable by me. Any balance remaining on the account after the insurance carriers are due immediately.
  10. Copays, deductibles, coinsurances, and any other payments required to be collected shall not be waived by Womick Podiatry Clinic.
  11. If you have insurance through an HMO, a referral form from your primary Care Physicians may be required before you can be seen in our office. This is a requirement of your insurance company, not Womick Podiatry Clinic. If needed, this referral must be acquired by the time of your appointment or we will not be able to provide service.
  12. Billing inquires may be directed at the front desk. Thank you for allowing Womick Podiatry Clinic, P.C., to participate in your healthcare needs.
  13. I also hereby acknowledge that I have recieved a copy of the Notice of Medical Privacy Practices of Womich Podiatry Clinic, P.C.

Disclaimer: 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 ARE SIGNING AS THE PERSONAL REPRESENTATIVE OF THE PATIENT

What to Bring to your scheduled appointment

  • Current Photo I.D.
  • Current Insurance Card(s)
  • Co-pay (if applicable)* All co-pays are to be paid before services are rendered. NO EXCEPTIONS. WE DO NOT BILL FOR CO-PAYS. Check or call your insurance company for your co-pay information.
  • Current list of medication(s) including all over the counter medications and vitamins.
  • If your insurance is an (HMO) plan, contact your (PCP) Primary Care Doctor to see if a referral is needed for this visit.

Please be sure to arrive 15 minutes early for your appointment to fill out any necessary paperwork and to ensure that you will be seen on time.

Please mark your calendar!

We look forward to seeing you and please have a happy and healthy day.

-Womick Podiatry Staff

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