PATIENT INFORMATION FORM

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Patient Name:

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INSURANCE INFORMATION

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS) OR ATTACH LIST:

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PLEASE LIST ALL PRIOR SURGERIES:

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    SOCIAL HISTORY

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    FAMILY HISTORY (LIST ANY MEDICAL ISSUES THAT RUN IN YOUR FAMILY (HEART,ARTHRITIS,DIABETES, ETC)

    YOUR MEDICAL HISTORY

    ALLERGIES:

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    DO YOU HAVE ANY OF THE FOLLOWING:

    CURRENT PROBLEM

    TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS.

    I ALSO REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE, HMO OR INSURANCE BENEFITS BE MADE EITHER TO ME OR ON MY BEHALF TO LANCASTER COUNTY PODIATRY FOR ANY SERVICES FURNISHED ME BY PHYSICIAN OR SUPPLIER. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE CENTERS FOR MEDICARE SERVICES AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES. I AUTHORIZE LANCASTER COUNTY PODIATRY, ITS EMPLOYEES OR MEDICAL PROVIDERS TO RELEASE ALL INFORMATION FROM MY MEDICAL RECORD THAT MAY BE REQUIRED FOR PAYMENT OF MY CHARGES BY MY INSURANCE COMPANY. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO PAY FOR ANY CHARGES NOT COVERED BY OTHER SOURCES.

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