New Patient Packet

Please correct the errors described below.

Patient Demographics Form

Insurance Information

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.

FINANCIAL RESPONSIBLE PARTY (If different from patient)

Medicare Authorization

I, the undersigned, request that payment of authorized Medicare benefits be made on my behalf directly to John Murphy, DPM for services rendered. I hereby authorize the doctor to release to the Centers for Medicare and Medicaid Services (CMS) all information necessary to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes the release of medical information necessary to pay the claim. If “other health insurance” is indicated in Section 9 of the HCFA 1500 claim form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or the supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-payment, and charges associated with non-covered services. Co-payments and deductibles are based upon the charge determination of the Medicare carrier.

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.

USE AND DISCLOSEURE OF PROTECTED HEALTH INFORMATION

The HIPAA educational pamphlet provides information about how Maryland Podiatry Center may use and disclose protected health information about you, and is compliant with the requirements of the Health Insurance Portability and Accountability Act of 1996(HIPAA).

We reserve the right to change the items described. Should this happen, you will receive a revised copy. You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or health care operations. We are not required to agree to your restrictions, but if we do, we are bound by our agreement with you. By signing below, you acknowledge receipt of our HIPAA regulations.

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.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

(Effective Date: April 14, 2003)

(**NOTE: You have the right to refuse to sign this Form)

For professional Use Only

Medical History Form

The following information is very important to your health. Please be complete.

CURRENT FOOT/ANKLE PROBLEM

MEDICAL HISTORY

Please check only what applies for personal or family medical history of any of the following:

MEDICATIONS

ALLERGIES

List surgeries within the last 10 years:

Add Information

WOMAN

TOBACCO

ALCOHOL

DRUG USE

FINANCIAL POLICY

Thank you for choosing our office to provide you with your foot and ankle needs. Our commitment to you will hopefully meet your expectations. The services provided by the office necessitate a financial responsibility from our patients. The following summarizes the financial areas of concern.

NO SHOWS & SAME DAY CANCELLATIONS: We have a 24 hour cancellation
policy. No Shows and same day cancellations will be charged $50

CO-PAYS:
These payments will be collected each visit prior to being seen.
SELF PAY:
If health insurance is not available, payment will be expected in full the day of service.

MEDICARE:
The office participates with Medicare and the bill will be submitted for you, any co-pay or deductible will be the patient’s responsibility, as stated by Medicare and secondary insurance.

SECONDARY INSURANCE:
After payment from primary insurance is received, the secondary insurance company will be billed, as necessary.

REFERRALS/AUTHORIZATIONS:
It is a legal agreement that we follow the guidelines of your insurance company. If you need a referral to be seen by a specialist, then it is your responsibility, not this office, to have it available the date of your visit. If a referral, which is required to be seen, is not present at the time of your visit, then the financial responsibility for services delivered will be placed on the patient. You have the option of rescheduling your appointment to a later date.

PATIENT BILLING:
Please let the office know of any hardship you may have with payment of your bill. After the third notice to collect your responsibility of payment after the primary insurance and secondary insurance (if applicable) the account will be forwarded to a collection agency. Any returned checks will result in $30.00 added to your statement. Methods of payment include cash, Money Order, check or credit card.

PRIVACY STATEMENT
Any information disclosed in your records will remain confidential and will not be used for any reason except in providing quality care and treatment as well as to submit your claim to your insurance company and contact you as needed.

I have read the above policy regarding my financial responsibility to John Murphy, DPM LLC for providing medical services to me or the below named patient. I agree to pay any amount due after insurance payment has been made by my carrier and any contractual adjustments have been credited or the full amount of all bills incurred by me or the below named if no health insurance exists.

ASSIGNMENT OF BENEFITS
I, the undersigned, certify that I (or my dependent) have coverage with my insurance company as presented and assign directly to John Murphy, DPM LLC all insurance benefits payable to me for services rendered. I understand that I am responsible for all co-pays, deductibles, and non covered services. I hereby, authorize the doctor to release all information necessary to secure payment of benefits. I authorize the release of medical information to my insurance carrier or requested physician to provide continuity of care. I authorize this signature on all insurance submissions.

I understand it is my responsibility to inform my doctor of any change in my health insurance information.

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.

Assignment of Benefits & Authorization to Release Information to My Insurance Company

I, the undersigned certify that I (or my dependent) have insurance coverage with the above plan(s), and hereby assign all insurance benefits, if any, otherwise payable to me, directly to John Murphy DPM for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance.

I hereby authorize the doctor to release all information necessary to secure the payment of benefits from my insurance company(s).

I authorize the use of my signature below to reflect my agreement and authorize for the above for all insurance submissions.

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.

CONSENT

I certify that the above information is true and correct to the best of my knowledge
I give my permission for John Murphy, DPM to examine, photograph, administer and perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot and/or ankle problems.

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.

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I was 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.

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.

If applicable only for caregivers, guardians, or anyone who will be present in exam room)

to be in the exam room during my treatments, participate in my care or have access to my records

Your information will be encrypted.

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