New Patient Information

If there is a person you would like us to share your medical information with, please provide their name, phone number and relationship.

Release and Assignments

I, the undersigned, hereby authorize the release of all information necessary to secure the payment of benefits submitted for services rendered by my physician/provider on behalf of myself and /or my dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician/provider to submit claims for benefits for any services rendered without obtaining my signature on each and every claim form and that I will be bound by this signature as though the undersigned had personally signed the particular claim.
I, the undersigned have coverage with the insurance company listed above and assign directly to Gibbons Foot and Ankle Group all claim benefits if any. Otherwise payable by me for services rendered. I acknowledge and understand that I am financially and fully responsible for all charges incurred from the service rendered by my physician whether or not paid by the insurance. If any portion of my account balance is not reimbursed by my insurance company for any reason, I agree to cooperate and arrange payment in full to clear my bill. I understand payment is due upon receipt of my monthly statement.
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.

History and Physical Examination

Social History

Family History (Write Mother or Father)

I hereby give permission to Gibbons Foot and Ankle Group to examine and/or administer treatment necessary in the diagnosis and/or treatment of my foot problems. I hereby give my consent for Gibbons Foot and Ankle Group Care to use and disclose protected health information about me to carry out the treatment. I hereby, authorize payment to the physician providing services for which benefits are payable.
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.

Welcome to Gibbons Foot and Ankle Group We appreciate your confidence in our office and we will strive to exceed your expectations regarding your foot care needs. Our goal is to treat foot conditions and drastically improve the quality of life to those suffering daily with foot pain.
We participate in numerous insurance plans and will gladly handle the paperwork required to efficiently and effectively submit claims directly to each different carrier. However, if you have an insurance plan that requires a referral from your primary care provider in order to be seen it is your responsibility to secure the referral by the time of your visit. Unfortunately, we are unable to obtain retroactive referrals and the insurance company will not pay for treatment without a valid referral in place.

Please be aware that verification of coverage is not a guarantee of payment. Decisions of payment are made at the time the claim is received by our insurance carrier.

Additionally, please note that many insurance plans have deductibles. It is the responsibility of the patient to be aware of their deductible and understand they will be billed for any balances that may occur. Also, many insurance companies are no longer paying for "routine foot care" (cutting of nails, calluses, and corns). We encourage you to read through your current insurance policy for any restrictions. Non-covered services will be billed directly to the patient.
Please do not hesitate to ask our staff if you have any questions.
I acknowledge that I have read this letter and understand its contents.
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.

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add delete or modify any of these provisions to better serve the needs of the both practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

do hereby consent and acknowledged my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

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.

For Medicare Patient Form

Gibbons Foot & Ankle Group | 281 Summerhill Rd Ste 102, East Brunswick, NJ, 08816, US

FOR MEDICARE PATIENTS

I requested that payment of authorized Medicare benefits be made to Gibbons Foot and Ankle Group for any services furnished by said physician and/or supplier. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and/or its agents regarding any information needed to determine these benefits or the benefits payable for related services.
I understand that Medicare will only pay for services that it determines to be reasonable and necessary under Section 1862(a) of the Medicare law. If Medicare determines that a particular service, although it would be otherwise covered is "not reasonable and necessary" under Medicare program standards, Medicare will deny payment for that service. We believe that in your case, Medicare is likely to deny payment for Debridement of Mycotic Nails for the following reasons: Medicare usually does not pay for like services by more than one doctor during the same time period and/or Medicare usually does not pay for this many services within this period of time.

BENEFICIARY AGREEMENT

I have been notified by my physician that he believes that, in my case, Medicare is likely to deny payment for the services identified above, for the reasons stated. If Medicare denies payment I agree to be personally and fully responsible for payment.
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.