• Please provide a copy of your current insurance cards.
• Co-Pay, Co-Insurance & Deductibles are expected at the time of service.
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)
With another Person(s):
Email or Patient Portal:
*****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 Cards/Documentation must be given to front desk at time of service ***
(Person responsible financially and/or patient is a minor)
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)