New Patient Paperwork

Please correct the errors described below.

Patient Information

Medical Insurance/Policy Holder

Responsible Party/Guarantor

Assignments of Medical Benefits/Authorization to Release Medical Information

I hereby authorize payments of medical benefits directly to physician for Medical Services provided. I authorize the Physician to release any information acquired in the course of any treatment necessary to process insurance claims to my insurance provider.

Privacy Practice agreement has been given to me to read. I fully understand all the information. If I have any questions I understand I can contact the Privacy officer at 770-675-7904. This notice discusses how my medical information may be used and disclosed as well as my rights as a patient. If any changes are made to this Privacy Practice agreement, I understand the information will be posted in the waiting area and copies will be available to me upon request.


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.

Diabetic Patients Only

Medical History

Current Medications & Dosage

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Patients 65 and over

Updated Vaccinations

Allergies

Social History

Women only


I believe I have answered all the questions on this form to be best of my knowledge. It is my responsibility to advise the physician and office staff of any changes in my medical history. I understand if I have answered any of the questions incorrectly it could affect my treatment by the physician. I hereby authorize the physician and his or her assistants of Southeast Podiatry to administer treatment as deemed necessary.


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.

Financial Policy

1. If your plan requires a referral you must obtain this referral prior to being seen otherwise you will be responsible for all charges at time of visit. It is your responsibility to make sure that the physician is covered under your insurance network. You will not be seen require referral is not obtained and you refuse to pay for office visit.

2. All Deductibles, Co-pays, Co-Insurance and Out of pocket expense will be collected at the time of service.

3. We will file your claim for you if we are a participating provider in your plan. You will be responsible for any and all services in excess of your insurance limits as well as all non-covered services, durable medical equipment, and supplies.

4. We will mail you a statement for any outstanding balances not covered by your insurance for any reason.

5. Unpaid past due balances must be paid prior to seeing the physician for any appointments schedule unless a payment arrangement is in effect with the billing department.

6. In the event we have to send your account to debt collections, there will be a $50.00 processing fee added to the outstanding balance.

7. It is your responsibility to provide correct insurance information, present an insurance card, and state issued identification at the time of your appointment.

8. There is a $30.00 returned check fee charge

9. To receive copies of your medical records a signed medical release form must be completed and records will be dispensed within 48-72 hours. There may be a charge for release of medical records. Fees will be due prior to receipt of these records.

10. There is a $15.00 charge for any disability forms, Family Medical Leave, and any other forms for administrative purposes. This fee is charged each time forms are to be completed.

11. Our office reserves the right to charge a $25.00 No Show/Cancellation Fee to any patient who fails to cancel their appointment without a 24 hour advanced notice. This fee will be billed directly to you and is nor reimbursable by insurance.


By signing below, you acknowledge that you understand and accept this financial policy.


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.

Authorization to Discuss Medical Information

I hereby authorize you to use or disclose the specific information described below only for the purposes described below.

I authorize the release of information to the following:

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This authorization shall remain in effect from the date signed below until


I understand that:

  • I may inspect or copy the protected health information to be used or disclosed.
  • I may revoke this authorization in writing by contacting your office, attention Administrator.
  • This authorization is giving Southeast Podiatry the right to discuss my medical information with the one or more people listed above.
  • Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and will no longer be protected by HIPAA.
  • The physician will forward record of my office visit and treatment plan to my Primary Care Physician unless otherwise stated.


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.

Authorization to Leave Message

From time to time in caring for our patients, it may become necessary to contact you by telephone. Often our patients are not available when we call and we would like to be able to leave a detailed telephone message (i.e. lab results) when possible. In order to protect your privacy we need your written permission to leave detailed telephone messages on your answering machine, voice mail system or with a trusted family member. Please read the following choices and tell us whether or not we can leave voice mail regarding your medical information, such as lab and test results, and with whom we may leave it.

Please choose one of the following:

CONSENT for Southeast Podiatry staff, to leave detailed telephone messages regarding my medical care with the following options:


By signing below, I authorize Southeast Podiatry through its vendor, Practice Fusion to contact me via automated text and voice messages to remind me of my upcoming appointments.

I understand that message/data rates may apply.

I know that I am under no obligation to authorize Practice Fusion to send me appointment reminder text messages or telephone calls.

I may opt-out of receiving these communications from Practice Fusion at any time by calling Southeast Podiatry at 770-675-7904, or email appointments@southeastpod.com.


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.

Your information will be encrypted.

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