Patient Information Form

INSURANCE INFORMATION

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

Please list all prior surgeries

Please list all prior hospitalizations (other then surgery):

Social History

Family history

Your Medical 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.

PATIENT and/or RESPONSIBILE PARTY - FINANCIAL AGREEMENT with Podiatry Associates, P.C.

We do file your insurance. You will be responsible for this account in the event that your insurance company does not pay the claim. The patient understands that no oral or written contract except for the patient and/or responsible party, responsibility for providing correct insurance information, and paying their account.

I, hereby authorize consent for the treatment necessary or desirable for my care/or the patient mentioned in this form. This includes, but is not restricted to, medicine, the performance of operation/procedures, and conduct of laboratory or x-rays, dispensing of supplies, that may be used by the attending doctor. The services you receive including supplies that are possibly covered by your insurance carrier will be filed to your insurance company if your insurance does not cover charges filed; the patient, and/or responsible party is responsible for payment of all non-covered services and supplies.

I, hereby acknowledge responsibility for the payment of all services, and agree to pay all amounts due in full at the time of service, (copay, deductible, non-covered items, supplies given to you by doctor or nurses; put in your shoes, etc. or services performed by the doctor not covered by insurance), unless other written arrangements are made.

, hereby authorize my insurance company to remit payment of medical benefits directly to this office for services provided by our physicians. Verification of insurance does not guarantee payment of the claim, if insurance does not pay or respond to the bill; I am responsible to contact the insurance and I agree to pay all charges not paid.

If I, (the patient) change insurance carriers, (example - if I have Medicare Part B insurance and you sign up for Health springs of Alabama, Viva, Secure Horizons, Advantra Freedom, Wellcare, Humana, Blue Advantage, United Healthcare, AARP, etc.), we must be informed of this change with a copy of the insurance card. Some insurance companies require referrals from your primary care provider as well as strict guidelines on the timely filing of claims. When any patient becomes Medicare age and signs up for Medicare Part B, it is the patient's responsibility to show our office their Medicare Card. It is also the patient's responsibility to contact Medicare and inform them of any primary or secondary insurance updates/changes. I understand that it is my responsibility to make sure our office has the correct insurance information and a copy of the correct insurance card. I also understand that I am responsible for providing our office with a picture ID {such as a current driver's license), to keep on file as proof of who I am.

If my insurance requires prior authorization for visits to Podiatry Associates, PC: Dr. Robert I. Russell - Dr. James H. Bowman - Dr. Stewart Pierson; it is the patient's responsibility to call their primary care physician's office to obtain authorization. Podiatry Associates must receive authorization prior to the appointment date; if we do not receive the authorization by the appointment date, the patient will be required to pay for the visit in full or reschedule the appointment.

In the event, the correct insurance information for any of my visits and my insurance had changed and the correct information was not given to Podiatry Associates; it is the patient's responsibility to pay for services denied by the insurance carrier. Some insurance companies have a 45 -180-day filing limit. Medicare has only 12 months to file a claim from the date of service. Podiatry Associates must have the correct information to file charges within the filing period or the patient is responsible for the charges in full.

There are some services and items for maintenance of good health that may not be covered by my insurance carrier, (example: items that go into the patient's shoes or used on t their feet or nails; services not considered medically necessary by some insurance company standards), I understand ( I the patient) is responsible to pay for these items.

Not all insurance companies cover Supplies, Orthotics, and Therapeutic (Diabetic} shoes. All coverage of benefits is determined by insurance carrier/group: it is best to check with your insurance company on your coverage and exclusions on foot care or Podiatry services, copay, and deductible amounts. Supplies and specially ordered items such as: (Orthotics, Diabetic shoes) cannot be returned and payment is non-refundable.

I, hereby authorize the release of all medical records on the patient listed above to the referring and/or primary care physician, as well as all records necessary for the processing of insurance claims when or if requested. I authorize information released to my Employer such as (Work Excuse, FMLA papers, etc). There is a fee for us to fill out papers for you, FMLA, disability, etc. If my account becomes delinquent, I the undersigned, accept the fee charged as a legal and lawful debt and agree to pay the said fee, including any/all collection agency fees. The fee can be an additional (33.33%), attorney fees and/or court costs if such be necessary and the debt will be reflected on your credit rating with any or all credit reporting agencies and you no longer will be able to be seen by our doctors until paid in full.

You agree, in order for us to service your account or to collect monies you may owe, Podiatry Associates, PC, and/or agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing devices, as applicable.

I/We have read all of the above and understand my responsibility as the patient and/or responsibility party and have agreed to all the disclosures mentioned.