New Patient Paperwork

Please correct the errors described below.

• Please provide a copy of your current insurance cards.

• Co-Pay, Co-Insurance & Deductibles are expected at the time of service.

Patient Information

Family/PCP Physician:

Pharmacy:

Please check all methods we may utilize to speak with you or to leave you a detailed message:

HOME Phone (including auto calls)

CELL Phone (including auto calls)

WORK Phone

With another Person(s):

Email or Patient Portal:

Mail

Emergency Contact:

*****Please list name of someone not living in your household*****

Complete Foot and Ankle Specialists, Inc. does not honor advanced directives. We will call 911 to provide life support to any patient in distress. After treatment, the patient will be turned over to their treating physician for continuing care and we will provide them with the name of your custodian of document you listed above.

INSURANCE INFORMATION:

*** Insurance Cards/Documentation must be given to front desk at time of service ***

Guarantor Information:

(Person responsible financially and/or patient is a minor)

Will this treatment be done as a result of:

Health Insurance:

INSURANCE AUTHORIZATION/ASSIGNMENT (PLEASE READ & SIGN)

I hereby authorize the physician to furnish information to my insurance carrier concerning my condition and treatment. I hereby assign to the physician all payments for medical service rendered to my dependent or myself. I understand that I am responsible for any amount not covered by my insurance carrier. I agree to be held responsible for collection processing fees that may be added to my account if collection action occurs.

(If the patient is a minor, the legal guardian must sign)

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PATIENT MEDICAL INFORMATION

List Prescription Medications Currently Taking: (Please ATTACH List)

Add another medication

FAMILY History: Has any member of your immediate family been treated for the following?

(Please check all that apply and select the appropriate family member.)

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.

Your information will be encrypted.

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