Patient Demographics and HIPAA

Reason for your visit:

Date:

First Name:

MI:

Last Name:

Jr Sr

Gender:

Male Female

Birthdate:

Email:

Address:

Apt. #:

City:

State:

Zip:

Primary Phone#

Cell/home?

Cell Home

Secondary Phone#:

Cell/home?

Cell Home

How did you find us?

Doctor Family/Friend Our Website Google Insurance Directory

Referred by:

Emergency Contact:

Relation:

Phone #:

Marital Status (Please Choose)

Single Married Partner Divorced Widowed Student

Is a referral needed?

Yes No

Referral Received:

Primary Insurance:

Insurance Company Phone #:

Copay:

Ins Plan Name:

ID #:

Group #:

Subscriber First Name:

Subscriber Last Name:

Relationship to subscriber:

Self Spouse Child

Subscriber Birth Date:

Secondary Insurance

Insurance Company Phone #:

Copay

Ins Plan Name:

ID #:

Group #:

Subscriber First Name:

Subscriber Last Name:

Relationship to subscriber:

Self Spouse Child

Subscriber Birth Date:

If the patient is insured under parents plan, please complete the following:

Legal Representative:

Mother Father Both

Mother's Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Father's Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

CONSENT FOR TREATMENT: I give Tola Foot & Ankle Center permission to examine and treat, perform tests and procedures that are necessary in the diagnosis and/or treatment of my foot/ankle/leg disorders.
FINANCIAL POLICY: I certify that I (or my dependent) have coverage with my insurance and am responsible for informing the office if there is any change in my health insurance information. For my visits in this office, I assign all insurance payments to be payable to Dr. Pamela F. Tola. I understand that I am responsible for payment of deductibles, co-payments, and/or non-covered services. I allow the release of medical information to my health insurance for payment, or requested physician for the purpose of treatment and/or to provide continuity of care. I authorize the use of this signature on all health insurance claim form submissions
PRIVACY NOTICE: I certify that I have read (or had the opportunity to read if I so chose) and understand the HIPAA Notice of Privacy Practices. Our office’s full HIPAA policy is available upon my request.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

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