New Patient Forms

North Avenue Podiatry Services, P.C.

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WELCOME TO OUR OFFICE

So that we might serve you better, please complete as fully as possible. This information will be kept confidential as required by Federal and State Health Information Privacy Laws. We would like this opportunity to inform you of Your Rights and Privacy Practices utilized by this office. Enclosed for your convenience is a "Summary of Notice of Privacy Practices." A detailed description is available and posted throughout our office. You may request your own copy at any time. Once you have reviewed the "Summary of Notice of Privacy Practices• or the detailed "Notice of Privacy Practices" please sign the attached Acknowledgment and the Authorization/Assignment of Benefit Claims forms.

(if different than Patient's)

*This information is for reporting purposes only and is strictly voluntary.

Medical Information

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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.

For our "MINOR" patients, our office policy is that the parent or legal guardian who brings the patient into the office for their appointment, will be the "responsible party" for outstanding balances. Therefore, we will need this additional information:

Review of Systems

Please check if you have any of the following conditions.

Insurance Information

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For self pay patients, it is customary to pay for services when rendered unless other arrangements have been made in advance with our office.

Authorization and Assignment

I request that payment of authorized Medicare/Other Insurance company benefits be made either to me or on my behalf to North Avenue PodiatryServices, P.C., for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to release to HCFA and its agents any information needed to determine these benefits payable to related services. I understand my signature requests that payment be made and authorizes the release of medical information necessary to pay the claim. My signature authorizes releasing of the information to the insurer(s) or agency(s) shown. In Medicare/Insurance programs that my physician participates (signed contract) with, the physician or supplier agrees to accept the charge determination of the Medicare/Contracted Insurance Company as the full charge and the patient is responsible only for the deductible, the Coinsurance, and the non-covered services. I understand that I am ultimately responsible for all fees regardless of insurance coverage and that my physician will attempt to bill my insurance twice before turning the charges over to me. Coinsurances and the deductible are based upon the charge determination of the Medicare/Other Insurance Company.

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understood the notice.

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