New Patient Forms - English - HB Podiatry Group

I. PATIENT INFORMATION

Patient:

Date:

Address:

City:

State:

Zip:

Sex:

M F

Age:

Birthdate:

Email:

Patient SS #:

Occupation:

Employer:

Employer Address:

Employer Phone:

Spouse's Name:

Birthdate:

SS #:

Occupation:

Spouse's Employer:

Whom may we thank for referring you?

II. INSURANCE

Who is responsible for this account?

Relationship to Patient:

Insurance Company:

Group #:

Is patient covered by additional insurance

Yes No

Subscriber Name:

Birthdate:

SS #:

Relationship to Patient:

Insurance Company:

Group #:

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have coverage with:

and assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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.

Responsible Party Signature:

Relationship:

Date:

MEDICARE AUTHORIZATION

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. [Enter Doctor's Name Below] for any services furnised me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature request that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determine of the Medicare carrier.

Relationship:

Date:

III. PHONE NUMBERS

Home:

Work:

Ext:

Best time and place to reach you:

IN CASE OF EMERGENCY, CONTACT:

Name:

Relationship:

Home Phone:

Work Phone:

IV. PODIATRIC HISTORY

What is the chief complaint for which you came to be treated?

Have you ever been to a Podiatrist before?

Yes No

If yes, please list name:

Last visit:

Is there any personal or family history of diabetes?

Yes No

Your occupation:

Cigarette/Tobacco use:

Years smoked:

Athletic activites in which you participate:

V. MEDICAL HISTORY

Surgeries you have had:

Hospitalization other than for the surgeries listed:

Family Physician:

Last visit date:

Are you now, or have you been, under any other doctor's care for any reason over the past two years?

Yes No

If Yes, please explain:

VI. MEDICATIONS

Add another medication

Do you take oral contraceptives?

Yes No

VII. ALLERGIES

If Others, please specify:

CONSENT

I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet.

Patient's Signture

Date

NOTICE OF PRIVACY PRACTICES

Patient Name:

I hereby authorize the use and disclosure of individually identifiable health information relating to me, which is "protected Health Information" (PHI) under a federal health privacy law, for the purpose of treatment, payment and healthcare operations. PHI is basically health information that is identifiable to an individual and this is transmitted or maintained in any form or medium, including oral, paper, or electronic, by a health care provider, (Healthcare provide includes any person or organization who furnishes, bills, or is paid for health care in the normal course of business. Provider includes physicians and all staff) PHI can be more than just medical records and charts. PHI includes information that relates to treatment, health condition, payment and even demographics information such as name, address and age. Disclosed PHI will cover all dates of service performed by the doctors and staff from HB Podiatry Group, at the office or patient's home.

Print Name:

(For personal representative, please indicate your relationship)

Signature:

Date:

Date of Birth:

Social Security Number:

ASSIGNMENT OF BENEFITS

I authorize and direct my insurance company or benefit program to provide a full and complete copy of the benefits and services available to me under my health care plan, program and/or insurance, including but not limited to all terms, conditions, limitations and exclusions of coverage, just as if I had requested such information.
I am finacially responsible for any co-pays, deductibles, or patient responsibility for all office visits, services, or supplies provided at time of visit, and fo all office visits, services, or supplies which are not authorized, or are denied per insurance company, or if I have no insurance benefits at time of service.
I authorize and direct my insurance carrier to pay medical benefits directly to HB Podiatry Group, Inc.
I understand that if I receive payments due to my physician for charges I have uncurred for medical treatment, it is my responsibility to remit to HB Podiatry Group ASAP.
I understand and agree that if I fail to cooperate with my insurance company in processing my claims, and payment is denied, I am financially responsible for the full charges.

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

Patient Signature:

(For personal representative, please indicate your relationship)

Print Name:

Your information will be encrypted.