Patient Registration Form

Patient Information

Patient First Name

M.I.

Last Name

Race

Decline

Ethnicity

Decline

Language

Sex

Male Female

Marital Status

Single Married Widowed Separated DP

Spouse/Partner Name

Spouse Date of Birth

Patient Home Street Address

Apt. #

PO Mailing address [if applicable]

City

State

ZIP

Patient Home Phone #

Cell Phone #

Patient email address

Would you like online access to your health record emailed to you?

Yes No

Patient Date of Birth

Age

Social Security Number

Patient Height

Patient Weight

Shoe Size

Patient Occupation

Employer Name

Employer Address

Phone Number

Preferred Pharmacy

BEST CONTACT INFORMATION

Home Phone Cell Phone Work Email

If patient is a minor – provide Name of parents or guardian

Address of parents or guardian

Home Phone #

Cell Phone #

Emergency Contact Name

Phone

Relationship

Payment and Insurance Information

Please present your insurance card and drivers license upon arrival

Check here if no health insurance

Full Name of Insured

Relationship to Patient

Insured SS#

Insured Date of Birth

Insured Employer

Employer Address

According to my insurance, I am responsible to pay a

a Co-Pay Amount

Deductible Amount

Payment today will be made by

Cash Check Visa Master Card American Express Discover

My insurance requires a referral from my PCP before I see a specialist.

Yes No

Referral Information

We appreciate your referrals! Who may we thank for referring you to our office?

Name

Address

Is this person your

PCP Other Specialist Family Member Friend

Other Referral Sources [check all that apply and please specify names where indicated]:

Internet Search

Name

Phone Book

Name

Our Practice Website

Newspaper Ad

Name

Saw your sign

Insurance Plan or Website

Name

Other

Explain

Podiatric History

Have you ever been to a podiatrist before?

Yes No

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

Affecting the

Right Left Both Feet/Ankles

When did it begin?

Did you receive treatment for this condition?

Yes No

If so, what type?

If selected "Seizure Disorder", please indicate type.

Medical History/Family History

Have you ever been treated for any of the following conditions?

Put an I if it applies to you, put an M if on your mother’s side; put an F if on your father’s side.

Anemia

Arthritis

Bleeding Disorders

Type

Cancer

Type

COPD

Depression

Diabetes

# of Years

Type

1 2

Insulin

Yes No

Fibromyalgia

Gout

Heart Attack

Heart Blockage

Heart Failure

Heart valve problems

Hepatitis

High Cholesterol

Hypertension

Irritable Bowel syndrome

Kdiney Problems Stones-infection-disease-failure

Liver Disease

Low Blood Pressure

Neuropathy

Peripheral Artery Disease

Parkinson’s Disease

Phlebitis

PVD

Psycosis

Rheumatic Fever

Stomach Ulcers

Varicose veins

Medications

Are you currently on Blood Thinners?

Yes No

You can provide a printed list of your medications or list them below:

Add new row

Do you currently use: Cigarettes or Tobacco?

Yes Never Quit

If yes, for how long?

How many pks/day?

If quit, when?

Alcohol use?

Yes No

If yes, quantity

Surgeries

Please list all surgeries

Add new row

Name of MD/Family Physician

Address

Date of Last Visit

Allergies

Have you ever had any adverse side effects or allergies to:

Adhesive Tape

Yes No

Metal/Jewelry

Yes No

Anticoagulants

Yes No

Novacaine

Yes No

Anti-inflammatory Meds

Yes No

Peanuts

Yes No

Aspirin

Yes No

Penicillin

Yes No

Codeine

Yes No

Seafood

Yes No

Cortisone

Yes No

Other antibiotics

Yes No

Iodine

Yes No

Other pain medication

Yes No

Latex

Yes No

Other

Yes No

If other, please explain

SIGNATURE ON FILE AND PERMISSION TO TREAT

I understand that the information provided on this form is true and correct to the best of my knowledge.
I request that payments of authorized benefits be made on my behalf for any services furnished by Arp Foot And Ankle Clinic,P.A.
I authorize any holder of information about me to release any information needed to determine these benefits or the benefits payable to related services to the insurance agent.
I recognize my financial obligation of any coinsurance, co-pays or deductibles and non-covered services that may be required.
I hereby give permission to Arp Foot And Ankle Clinic,P.A. and any qualified staff to evaluate, diagnose and treat my foot and/or ankle condition as may be 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.

Patient or Authorized Signature

If not patient, state relationship

Date

Financial Policy

Payment Policy

Thank you for choosing Arp Foot And Ankle Clinic, P.A. as your foot care provider. We are committed to providing you with quality and affordable health care. Please read the following office payment policy and feel free to ask us any questions that you may have. Once you accept this policy, kindly sign in the space provided. A copy will be provided to you upon request.

1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

3. Non-covered services. Please be aware that some - and perhaps all - of the services you receive may be uncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. If required, obtaining the proper referral from your Primary Care Physician is your responsibility. Patients presenting to our office without a valid referral will be asked to pay in full. This payment will be held for 48 hours and will become non refundable if the proper referral is not obtained by then.

5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company.

6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. Nonpayment. Invoices are sent out every 30 days. Your prompt payment will assist us in keeping the cost of healthcare down. If your account is over 60 days past due, you will receive a letter requesting immediate payment. A $10.00 rebilling fee will be charged for each additional invoice sent out after 30 days. Partial payments will not be accepted unless otherwise approved by our Billing Department. Please be aware that if a balance remains unpaid, we may refer your account to small claims court and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative podiatric care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

8. Missed appointments. Our policy is to charge $25.00 for missed appointments not canceled within a reasonable amount of time or for an understandable reason. Separate fees will apply for missed surgical appointments. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

9. Forms and Documents. It is our policy to charge $10.00 for completion of all forms, such as disability applications, etc.

10. Fees. Our fees are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read and understand the payment policy and agree to abide by its guidelines:

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.

Signature of patient or responsible party

Date

Privacy Statement

The Arp Foot And Ankle Clinic,P.A. will use and disclose your health information for the following purposes: to treat you, to assist other health care provides in treating you, to allow insurance companies to process insurance claims for services rendered to you, to obtain payment for services rendered to you and for certain limited operational activities, such as quality assessment, licensing, accreditation and training of students. Except as stated in more detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. If you have any questions, concerns or complaints regarding our privacy practices, please refer to the actual Notice of Privacy Practices provided to you for the person(s) whom you may contact.

Additional Disclosure Authority:

In addition to the allowable disclosures described in the State of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.

Please select your choice(s) below:

Any member of my immediate family

Yes No

Spouse Only

Yes No

Voicemail/Answering Machine

Yes No

Acknowledgement of Receipt of Notice of Privacy Practices

(Signature represents that I have been offered a copy of the policy)

I acknowledge that I was provided a copy of the Notice of Privacy Practices and have read (or had the opportunity to read if I so chose) and understood the Notice.

Signature

Date

Patient Name or Authorized Representative

Your information will be encrypted.