Patient Registration Form [English]

Family Podiatry Group of Tampa, P.A.

Please correct the errors described below.

PATIENT INFORMATION

REFERRING DOCTOR INFORMATION

INSURANCE INFORMATION

PLEASE READ & SIGN:

I understand that it is my responsibility to pay any applicable co-payments, deductibles, co-insurance, and any other balance not paid for by insurance. I understand that it is my responsibility to obtain a valid referral, if applicable, for all visits and if any claim is denied for no referral then I may be responsible for payment. I understand that it is my responsibility to advise the practice of any changes to any of the above information and if any claim is denied as a result of not advising the practice then I may be responsible for payment. I hereby authorize the doctor and/or the practice to release all information necessary to secure the payment of benefits. I authorize and assign all benefits to be paid directly to the practice. I agree that a photocopy of this agreement shall be as valid as the original.

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.

PODIATRY HISTORY

If yes, Please list:

add another podiatrist

Medical History

MEDICATIONS

Include prescriptions, over-the-counter medications and vitamins

Add another medication

ALLERGIES

Payments: Paitents are responsible for all fees including missed visits and returned checks. Interest and late fees may apply on past due balances. Payment is expected at the time services are rendered. Payments must be arranged before treatment.

I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to provide podiatric services. and medicines, submit my insurance form, consider my signature "on file" for payment , and release any & all records needed. I understand the privacy policy, and have read and understand the above and agree to be personally responsible for all charges & fees.

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.

Review of System

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