New Patient - Chantilly Demographic Form - 3914 Centreville Rd – Suite 200 – Chantilly, VA 20151 (P: 703.490.5599 F: 703.583.5995 )

PATIENT INFORMATION

Date:

Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

ext.

Cell Phone:

Email Address:

The best way to contact me is by:

Home phone Work phone Cell phone

Date of Birth:

Social Security #:

Gender:

Marital Status:

Minor Single Married Divorced Separated Widowed Engaged

Primary Care Physician:

Phone #:

Fax #:

Race:

American Indian or Alaskan Native

Black or African American

Native Hawaiian or Pacific Islander

Asian

White

Other

Other:

Ethnicity:

Hispanic or Latino Not Hispanic or Latino

Emergency Contact:

Relationship to Patient:

Home Phone:

Work Phone:

PATIENTS UNDER 18

Relationship to Patient:

Self

Spouse

Parent

Other

Other:

Accompanying Adult’s Name:

INSURANCE INFORMATION

Primary Insurance Company:

ID#:

Grp #:

Name of Insured:

SSN#:

Date of Birth:

Relationship to Patient:

Self Spouse Parent Other

Other:

Gender:

DO YOU HAVE ANY ADDITIONAL INSURANCE?

Yes No

IF YES, PLEASE COMPLETE THE FOLLOWING:

Secondary Insurance Company:

ID#:

Grp #:

Name of Insured:

SSN#:

Date of Birth:

Relationship to Patient:

Self Spouse Parent Other

Other:

Gender:

Name of Employer:

RESPONSIBLE PARTY

Relationship to Patient:

Self Spouse Parent Other

Other:

Name:

SSN#:

Date of Birth:

Gender:

Address:

City:

State:

Zip:

Phone:

Email Address:

Employer:

Occupation:

Work Phone:

PHARMACY PREFERENCE

Primary Pharmacy:

Address:

City:

State:

Zip:

Phone:

Who may we thank for referring you?

Financial Policy for Potomac Podiatry Group, PLLC

Payment in full is due at time of service unless prior arrangements have been made.
Office visit co-payments for our participating HMO/PPO insurances are due at the time of service. If we have to generate a billing statement to collect your co-payment there will be a billing fee of $6.00 added for the administrative costs of billing.
If we are a participating provider with your primary health insurance, we are happy to file a claim on your behalf. However, once the insurance company is billed we allow 45 days for the balance to be paid by your insurance carrier. If the insurance carrier does not remit payment within 45 days, the balance will be due in full from you. If any payment is subsequently made by you insurance carrier in excess of the balance, we will gladly refund the overpayment to you within 30 days, providing that you do not have any outstanding accounts in our office.
HMO/PPO claim denials due to no referral or authorization are the patient’s responsibility. Office staff will notify and assist you in referral/precertification procedures, but final responsibility lies with the patient to comply with their specific insurance’s requirements. All referrals must be presented to our business office before seeing the doctor.
Please present your insurance card each time you visit if we participate with your plan to insure proper filing information to submit claims. *Otherwise your visit may not be covered and you will be responsible for payment.
There is a $25.00 charge for all returned checks.
Please be on time for your appointment. If you need to reschedule you appointment, we require a minimum of 24 hour notice. If you miss a scheduled appointment without notifying our office a $50.00 charge will be added to your account.
If your account must be forwarded to a collection service and/or an attorney because of non-payment, you will be responsible for all collection fees and/or attorney fees by these services.

ASSIGNMENT OF BENEFITS/PRIVACY POLICY

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Potomac Podiatry Group, PLLC all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co- payments, and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize RELEASE OF MEDICAL INFORMATION to my insurance carrier, or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions. I authorize Potomac Podiatry Group to use the Health Information Exchange Network in order to provide more comprehensive medical treatment.

By my signature I acknowledge reviewing the financial and privacy policies and hereby agree to their terms.

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.

Signature:

Patient Name:

Date:

I acknowledge receiving Potomac Podiatry Group’s Notice of Privacy Practices (posted in the office and on the website).

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.

Signature:

Date:

I authorize the following individuals to receive information on my behalf. This includes medical information.

Name:

Relationship:

Add Individual

REASON FOR VISIT

What is the chief complaint for which you came to be treated?

Have you ever been to a Podiatrist before?

Yes No

If yes, please explain:

Athletic activities in which you participate:

TOBACCO/SOCIAL HISTORY

Smoking Status:

Are you a Tobacco User?

Yes No

If yes, how many packs per day:

How many years:

Please select:

Current Smoker everyday Heavy Tobacco Smoker Light Tobacco Smoker Former Smoker Never Unknown, if ever smoked

Do you drink alcohol?

Yes No

Do you use Drugs?

Yes No

OTHER SOCIAL HISTORY:

GENERAL MEDICAL HISTORY

OTHER MEDICAL HISTORY:

HOSPITALIZATIONS:

SURGICAL HISTORY

MEDICATIONS (include prescriptions, over-the-counter & vitamins)

Medication:

Dose:

Add Medication

ALLERGIES

No known allergy history

Adhesive/Tape

Reaction:

Anti-coagulant

Reaction:

Aspirin

Reaction:

Codeine

Reaction:

Demerol

Reaction:

Iodine

Reaction:

Latex

Reaction:

Local Anesthetic

Reaction:

Novocain

Reaction:

Penicillin

Reaction:

Seafood

Reaction:

Sulfa

Reaction:

Other

Other:

Reaction:

FAMILY HISTORY

Mother Past Medical History:

Father Past Medical History:

Brother Past Medical History:

Sister Past Medical History:

Other:

ADDITIONAL CLINICAL NOTES:

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