Patient Registration

Patient Information

Appointment Date:

Legal Name

Address

City

State

ZIP

Phone Number

Email address

Date of Birth

Spouse / Partner Name

Phone

In case of an Emergency

Name

Relationship

Contact Number

How did you hear about us?

Google/Web Family member Friend Referral

Podiatric History

Reason for Today’s Visit

Duration

Location

Onset

What Makes it Worse

What Makes it Better

Treatments Tried

Height:

Weight:

Your occupation

Date quit smoking

Previous Foot / Ankle problems / Trauma History with Dates

Primary Care Physician (PCP) Name:

Date Last Seen:

Address:

Phone

Add Medications

Review of Systems:

Do you have or have you had any of the following: (check all that apply) (Bring additional Attachments to your visit, or can email Attachments to footclinic@aol.com, if necessary.)

ALLERGIES & Reactions

Medical History (May describe any conditions above, or other conditions not listed above)

Past Surgery History (Include Sx Date(s) & include Childbirth Date(s))

Family History (medical problems)

Additional comments about your foot conditions today:

DISCLAIMER: By typing your name in all of the designated signature areas, you are electronically signing these forms (all forms in this packet, which are part of, & included in, the Patient Registration process). You agree that your electronic signature is the legal equivalent of your manual signature on this application. Please type/sign your name below to accept this form of digital signature.

Signature

Date

Consent to Obtain Patient Medication History & Treatment Consent

Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.
The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially, dangerous drug interactions.

Date of Birth

hereby, give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, as well as my health plans and my other healthcare records from my other healthcare providers, as necessary. And, I, hereby, give my consent to Dr. Costache, Dr. Derickson, and the supporting medical staff, to administer and perform the procedures that the doctor deems medically necessary.

Signature

Date

Health Insurance/Self-Pay

Who is responsible for the account?

Relationship to Patient

1.) INSURANCE OPTION

INFORMATION ALREADY PROVIDED:

(If insurance has not yet been provided, please fill in the information below.)

1° Insurance:

Member ID#:

Group #:

2° Insurance:

Member ID#:

Group #:

If Policy Holder is different from patient, please provide the Policy Holder's information:

Policy Holder's Name:

Date of Birth:

Phone Number:

Address:

Insurance disclaimer:
"A benefit and/or authorization for appointment does not guarantee payment or actual eligibility. The payment of benefits is subject to all the terms, conditions, limitations and exclusions of the member's insurance contract at the time of service."
Payment insurance responsibility:
Your health insurance company will only pay for services it determines to be "reasonable and necessary." The office will do everything possible to have all services and procedures previously authorized by your health insurance company when prior authorization is required. It is possible that your health insurance company may deny a service that is not included in your health insurance plan.
Beneficial Additive:
If my health insurance company denies the payment, I agree to be personally and fully responsible for the payment. I also understand that, if my health insurance company makes the payment for the services, I will be responsible for any co-payment, deductible, or coinsurance that is applied at the end of the service.

2.) SELF-PAY OPTION:

Self-Pay Payment Responsibility: I agree to be personally and fully responsible for the payment that is applied at the end of the service.

By signing below, you agree to all checked options indicated on this page and have provided accurate information.

Signature:

Date

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge that I was provided a copy of, or access to, the Notice of Privacy Practices, and that I have read, or had the opportunity to read if I so choose, and understand the Notice of Privacy Practices.

Patient’s Name:

Parent or Authorized Representative (if applicable):

Signature:

Date

NEW HIPAA REGULATIONS

As of October 2002, HIPAA (Health Insurance Portability and Accountability Act) Regulations require a consent form to be signed by all patients regarding patient confidentiality.

allow Dr. Costache, Dr. Derickson, and/or any staff member to leave information regarding myself:

Please mark each of the choices that are applicable:

Leaving the above information:

With my spouse, family member, and/or dependent, as listed on Page 1 of Patient Registration.

May list additional names with relations here:

On an answering machine/voicemail, which is from a listed phone number on my account.

About information regarding:

Radiology or Lab Results

Appointment Dates and Times

Accountant Information (insurance, billing, collection information via email or fax)

Signature

Date

*SCHEDULED APPOINTMENTS*

We are aware that delays can happen, however, we try to keep all of our patients and our providers on time. If a patient arrives 15 minutes or more, past their scheduled time, we will have to RESCHEDULE the appointment. Please call if you are running late or are not able to make it to your appointment. Thank you.

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