Patient Information Form

Please correct the errors described below.

Insurance Information

Your Medical History


Please list all medications you are currently taking (include prescriptions, over-the-counter meds and herbal supplements)


Name strength and dosage

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Please hand list to the front desk staff if you have one.


ALLERGIES

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Please hand list to the front desk staff if you have one.


Please list all prior surgeries

Type of Surgery

Date

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Have you ever had any of the following:


REVIEW OF SYSTEMS (Please check the box if you currently have any of these symptoms or check "NONE")

CARDIOVASCULAR


GENITOURINARY


GASTROINTESTINAL


INTEGUMENTARY


HEMATOLOGIC


NEUROLOGICAL


MUSCULOSKELETAL


RESPIRATORY

Family History

FAMILY HISTORY

Is there any family history (blood relative) of: (please indicate family member)

Social History


CURRENT PROBLEM


To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status.


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.

GUARANTEE OF PAYMENT

For and in consideration of the services provided to the patient, I agree to the following:

I promise to pay Total Foot and Ankle of Tampa Bay for all charges of services rendered to or on behalf of the patient.

It is the policy of this office to file all Medicare and secondary claims. In addition, Total Foot and Ankle of Tampa Bay will file private insurance as a courtesy to our patients. I understand that it is my responsibility to pay remaining amounts that insurance does not pay.

I understand that all co-pays and deductibles, and over-the-counter product fees will be collected at time of service.

In the event that a check for payment on my account is returned, for any reason, I will be responsible for the payment plus the maximum service charge allowed according to Florida State Statute 832.08(5) and 68.065(2)

If Total Foot and Ankle of Tampa Bay determines my account must be placed with a credit reporting agency or an attorney for collections, I will be responsible for the cost of collection including attorney fees.

Total Foot and Ankle of Tampa Bay shall make all reasonable efforts to assure that the insured is covered by the plan, but I understand that ultimately it is my responsibility to establish and understand my insurance benefits.


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.

Release of Information

I authorize Total Foot and Ankle of Tampa Bay to release any medical or other information about me and the course of my treatment to any legal counsel, physician or insurance company requesting this information. I hereby release Total Foot and Ankle of Tampa Bay from any liability that can arise as a result of the use of the information contained in the records release.

Additionally, Total Foot and Ankle of Tampa Bay may release my health information to:

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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.

Charge for Forms

I understand that there is a charge for all forms that I may need to be filled out or copied by Total Foot and Ankle of Tampa Bay:

Copied and faxed forms or forms given to patient: $1.00/page for the first 25 pages; then .25/page for any additional pages

There is a $25.00 fee for all forms that need to be filled out by the staff or by the doctors.

Notice of Privacy Practices

This notice describes how your health information may be used and disclosed, and how you can access this information. Please review it carefully.

At Total Foot and Ankle of Tampa Bay, we are required to keep your health information secure and confidential, by law. Also by law, we need to give you this notice and to follow the terms of this notice.

The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by a specialist doctor whom we may involve in your care.

We may use or disclose your health information for payment of your services. For example, we may send a report of your treatment or progress to your insurance company.

We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your treatment information into our computer system.

We may share your medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy.

We may use your information to contact you. For example, we may send newsletters or other information to you. We may also call and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone.

In an emergency, we may disclose your health information to a family member or another person responsible for your care.

We will need to release some or all of your health information, when required by law.

If this practice is sold, your information will become the property of the new owner.

Except as described above, this practice will not use or disclose your health information without your prior written authorization.

You may request in writing that we not use or disclose some or all of your health information as described above. We will let you know if we can fulfill your request.

You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses.

You have the right to receive communication about your health information in the manner you prefer. We will also use whatever communication method, number or system you prefer to contact you.

You have the right to transfer a copy of your health information to another practice. Notify us in writing of where you would like us to send a copy of your health information for you.

You have the right to see and receive a copy of your health information, with a few exceptions. Give us a written request regarding the information you want to see. If you want a copy of your records, we may charge you a reasonable fee for the copies. If you would like a digital copy of your records, let us know which type of file you would like and we will try to meet your needs.

You have the right to request an amendment or change to your health information, in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information.

You have the right to receive a report of who we disclose your information to.

If our privacy and security measures or systems are breached in any way, we will notify you.

You have the right to receive a copy of this notice.

If we change any of the details of this notice, we will notify you of the changes in writing.

You may file a complaint with the Department of Health and Human Services in writing (200 Independence Avenue, S.W., Room 509F, Washington, DC 20201), online (http://www.hhs.gov) or by email (OCRComplaint@hhs.gov). You will not be retaliated against for filing a complaint.

Please contact our Privacy Officer, Claudia Valins, at (813) 788-3600 for more information, to make a request, to file a complaint with us or for assistance regarding your health information privacy.

Acknowledgment

I have received a copy of the Total Foot and Ankle of Tampa Bay Notice of Privacy Practices.


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.


Your information will be encrypted.

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