New Patient - Woodbridge Demographic Form

2280 Opitz Blvd, Suite 230, Woodbridge, VA 22191 (P: 703.583.5959 | F: 703.583.5995)

Please correct the errors described below.

PATIENT INFORMATION

PATIENTS UNDER 18

INSURANCE INFORMATION

IF YES, PLEASE COMPLETE THE FOLLOWING:

RESPONSIBLE PARTY

PHARMACY PREFERENCE

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.

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.

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

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REASON FOR VISIT

TOBACCO/SOCIAL HISTORY

Smoking Status:

GENERAL MEDICAL HISTORY

SURGICAL HISTORY

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

Add Medication

ALLERGIES

FAMILY HISTORY

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