New Patient Packet

Health History Form

Name

Sex

Male Female

Date of Birth

Height

Weight

Shoe Size

Local Pharmacy

Mail Order Pharmacy

Occupation

Do you drink alcohol?

Yes No

Do you smoke?

Yes No

Do you use illegal drugs?

Yes No

Exercise Level

None Occasional Moderate Heavy

Diet

Regular Gluten Free Diabetic

Past Medical History

Have you ever had any of the following conditions?

Are you currently experiencing any of the following

Anxiety

Yes No

Neuropathy

Yes No

Arthritis

Yes No

Gout

Yes No

Asthma

Yes No

Pregnant

Yes No

Atrial Fibrillation

Yes No

Leg Swelling

Yes No

Bone Marrow Transplant

Yes No

Unplanned Weight Loss

Yes No

Breast Cancer

Yes No

Dialysis

Yes No

Colon Cancer

Yes No

Edma

Yes No

COPD

Yes No

Foot Deformity

Yes No

Depression

Yes No

Nausea/Vomiting

Yes No

Diabetes

Yes No

Enlarged Glands

Yes No

Hearing Loss

Yes No

Joint Pain

Yes No

Hepatitis

Yes No

Muscle Aches

Yes No

High Blood Pressure

Yes No

Lymphoma/Leukemia

Yes No

HIV/AIDS

Yes No

Shortness of Breath

Yes No

High Cholesterol

Yes No

Problems Hearing

Yes No

Hyperthyoidism

Yes No

Others

Hypothyroidism

Yes No

Lung Cancer

Yes No

Pacemaker/Defibrillator

Yes No

Prostate Cancer

Yes No

Seasonal Allergies

Yes No

Seizures

Yes No

Stroke

Yes No

Surgical History

Family

Allergies

Please list all allergies & reactions to medications, food, etc.

Medications

Please list all medications including over the counter

Registration Form

Today's Date

Primary Care Provider

Patient Information

Patient's Last Name

First

Middle

Marital Status

Single Mar Div Sep Wid

Maiden Name

Race

Ethicnity

Hispanic/Latino Not Hispanic/Latino Refused

Birth Date

Age

Sex

M F

Social Security #

Address

Home #

Cell #

PO Box

City

State

Zip Code

Occupation

Employer

Employer Phone #

Preferred Pharmacy (with address)

Chose clinic because/Referred to clinic by (please check one box)

Dr.

Insurance Plan

Hospital

Family

Friend

Close to home/work

Yellow pages

Other

If Dr., please specify name.

Email address for portal registration

Insurance Information

(Please give your insurance card to the receptionist.)

Subscriber Name

Birth Date

Address (if different)

Home Phone #

Is this person a patient here?

Yes No

Occupation

Employer

Employer Address

Employer Phone #

Is this patient covered by insurance?

Yes No

Insurance Carrier

Insurance Address

Insurance Phone #

Birth Date

Group #

Policy #

Co-payment

Patient's Relationship to Subscriber

Self Spouse Parent Other

If other, please specify.

Name of Secondary Insurance

(if applicable)

Subscriber Name

Group #

Policy #

Patient's Relationship to Subscriber

Self Spouse Parent Other

If other, please specify.

In Case of Emergency

Name of Local Friend or Relative

(not living at same address)

Relationship to Patient

Home Phone #

Work Phone #

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dennis Robinson, DPM or insurance company to release any information required to process my claims.

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.

Patient/Guardian Signature

Date

Current Foot or Ankle Problem(s)

Please describe your current problem(s)

Specify area of pain or discomfort

Circle the type of pain you are experiencing

No Pain Sharp Pain Dull Pain Aching Burning Itching Radiating Stabbing Other

If other, please describe.

When did this problem start?

Did the problem develop suddenly or gradually?

What makes it feel worse (please check)?

Walking

Standing

Daily activities

Resting

Running

Certain shoes

Other

If other, please specify.

What makes it feel better?

How has this problem affected your lifestyle/ability to work?

If this was caused by an injury, please describe.

Work Related?

Y N

Statement of Medical History Accuracy "I have answered the questions on this form as accurately as possible. |understand that providing incorrect or misleading information can limit the physician's ability to accurately diagnose and treat my condition, it is my responsibility to inform the physician of any changes in my Medical status.”

Signature

Date

Responsible Person

(if other than patient)

Relationship

Date

Patient Receipt of Notice of Privacy Practices

Dr. Dennis Robinson, DPM has provided information regarding the Notice of Privacy Practices. This notice describes the practice's commitment to privacy, my rights to privacy, and how we may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

By signing this form, I am acknowledging that | have reviewed the Notice of Privacy Practices which explains how my medical and personal information will be used and disclosed. I understand that I am entitled to receive a copy of this document, upon request.

Patient Name

Signature of Patient/Personal Representative

Date

Relationship to Patient

Office Policies

A cellphone available to take your call after hours, weekends and holidays. If you are having a medical emergency please dial 911.

Any phone calls made during regular business hours will be addressed as soon as possible. If you feel that you have an urgent medical concern, please call for an appointment.

For all refills, please contact your pharmacy to fax our office a refill request within three business days before you run out of medication. We are not able approve refill requests after routine business hours.

For a printed copy of your medical/billing records, there is a fee of $30. Any records that consist of 28 pgs or more, there is a fee of 25¢ per page.

There is a $25.00 charge for all forma and letters to be completed by our office. Please allow 5-7 business days for completed paperwork.

We respect the strict confidentiality of the physician-patient relationship. We ask the same of you. By signing below, you agree that you will not make any recording of any person in this facility without their express written permission.

We encourage you to be an informed consumer by understanding your coverage, how to access information from your carrier, and which ancillary providers, e.g. lab and X-ray facilities, participate with your plan. Please inform us of changes to your demographics or insurance coverage.

I have read and understand the Office Policy of Dr. Dennis Robinson as stated above. I authorize medical care by the designated staff members. I authorize the release of any Patient Health Information necessary to process claims. I authorize payment of medical or government health benefits to the treating providers.

Signature of Patient/Legal Guardian

Name

Date

Patient’s Financial Responsibility Policies

Any applicable deductibles, co-insurance or co-payments are due at the time of service rendered as part of your insurance contract.

Uninsured Patients - The Office of Dr. Dennis Robinson, DPM offers a prompt pay discount to uninsured patients. Payments must be made at the time of services are rendered for discount to apply.

Patients Responsibility - The Office of Dr. Dennis Robinson, DPM can submit the claim of your visit on your behalf but it is your responsibility as a patient to keep your file with us updated. Any claims that are denied or ‘unprocessed due to lack of update information will be patients' responsibility. If a patient has an insurance that requires a referral, it's the patient's responsibility to make sure the office has the referral on the day of their appointment.

Insurance card (scan every year) and bring with you on every visit.
Address
Phone Number

Office Policies

We must be able to verify eligibility before services are rendered. If patient's insurance is not able to be verified due to ineligibility or a failing insurance system the patient can do the following:

Keep appointment and sign a waiver of responsibility
Reschedule until insurance is verifiable or eligible
If patient holds an HMO plan - Our provider must be selected as the primary care physician before we can actually render services.

Prompt Payment

In order for this office to keep negotiating and accepting the majority of insurance available to our patients and consumers in general; we are responsible for collecting deductibles and coinsurances from patients as part of the services render at time of services.

There is a $10 fee charge if Copays are not paid at the time of the visit.
There is a $30 fee for returned checks, which must be settled promptly with a credit card or cash only. If there are two or more instances of returned checks, all future payments must be paid via cash or credit card.

A $25.00 late cancellation/reschedule fee will be assessed for failure to provide any notice of cancellations for any provider appointment, ultrasound testing or procedure done in our office within 24 hours. A $50.00 No Show fee will be assessed for failure to show up to a scheduled appointment.

I have read and understand the Office Policy of Dennis Robinson, DPM as stated above and I understand I am responsible for any financial responsibility after Insurance has been processed or if I fail to provide the office with updated Information at time of service.

Signature of Patient/Legal Guardian

Name

Date

Authorization to Release Medical information to Individuals/Family Members

In accordance with federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your physician or staff of the Practice to discuss your condition or finances with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived.

I Do Not authorize the Practice to release any or all information concerning my medical care or finances to any individual.

I Do authorize the Practice to verbally release any or all information concerning my medical care or finances to the following individuals:

Add Authorized Individual

Signature of Patient/Legal Guardian

Name

Date

Authorization for Release of Medical Records

Patient Name

Date of Birth

Release Records To:

DENNIS L ROBINSON DPM

4131 Spicewood Springs Rd #L3

Austin, TX

78759-8491

(512)930-3753

Release Records From

Facility/Doctor Name

Fax Number

I request a copy or summary of the following Medical Records:

Complete Medical Records

Diagnostic Lab/X-Rays

Hospital Records

Other

All Records

If other, please specify.

I understand that the information in my health records may include information relating to sexually transmitted disease, acquired immunodeficiency syndromes, (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

Yes, I consent to the release of this information.

No, I do not consent to the release of this information.

Any other use of this information without the written consent of the patient is prohibited. However, I understand that any disclosure of information carries with it he potential for unauthorized re-disclosure and the information may not be protected by Federal confidentiality rules. I understand that I may revoke this authorization at any time by notifying my physician in writing, I understand that the revocation will not apply to Information already released in response to this authorization, I understand that the revocation will not apply to my Insurance company when the law provides insurer with the right to consent a claim under the policy.

This authorization will remain valid as long as fam under the care of

Signature of Patient/Legal Representative

Date

Relationship to Patient (if Legal Representative)

Date

Your information will be encrypted.