New Patient Paperwork

PATIENT INFORMATION

Patient Name:

Birth Date:

Sex:

M F

Date:

Address:

City:

State:

Zip:

Out of State Address:

City:

State:

Zip:

SS#:

DL#:

E-Mail:

Marital Status:

Married Widowed Single Separated Divorced

Phone Numbers

Home Phone:

Cell Phone:

In case of emergency, contact:

Name:

Relationship:

Phone:

How did you hear about us?

Google

Yahoo

Online

Patient

RefDoctor

YellowPages

Family

Friend

Have you ever been to a Podiatrist before?

Yes No

If yes, please list Name:

Last Visit:

Insurance Information

Name of Insured:

Name of PRIMARY Insurance:

Policy#:

Is patient covered by additional insurance?

Yes No

Add Secondary Insurance

INSURANCE ASSIGNMENT AND RELEASE

I request that payment of authorized benefits will be made on my behalf to Central Florida Foot and Ankle Center, LLC for any services furnished to me. 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 to related services. I understand my signature requests 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 assigned cases, the physicians or suppliers agree to accept the charge determination of the insurance carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, copay and/or non-covered on unpaid services. Coinsurance, copay, and the deductible are based upon the charge determination of the carrier.

DISCLAIMER: 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.

Signature of Patient, Guardian or Personal Representative

Date:

PODIATRIC HISTORY

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

Is this injury/problem related to:

Work

Yes No

Car accident:

Yes No

Personal Injury Case?

Yes No

Is there an ongoing lawsuit regarding this injury?

Yes No

Occupation/Job:

Cigarette/Tobacco use:

Years Smoked:

Shoe size:

Weight:

Height:

Are you in the past or currently on any type of street drug?

Yes No

If yes, what type of Drug?

Athletic activities in which you participate (please list and indicate frequency)

How long have you had the problem?

Describe your pain:

Please indicate which foot problems you have now or have had in the past.

Ankle Pain:

Yes No

Bunions:

Yes No

Corns and Calluses:

Yes No

Numbness in Feet/Legs :

Yes No

Flat Feet:

Yes No

Foot or Leg Cramps:

Yes No

Heel Pain:

Yes No

Ingrown Toenails:

Yes No

Rate your pain level (1-10):

If you checked Cancer, please specify what type:

If you selected Chemical dependency, please specify to what:

If you selected Diabetes, please specify how many years:

If you selected Diabetes, please specify what type:

If you selected Hepatitis or Jaundice, please specify what type:

If you selected Hepatitis or Jaundice, please specify when:

If you selected Psychiatric Care, please specify when:

If you selected Other, please specify:

Family Physician:

Date of last visit:

Surgeries you have had:

Allergies (Please list):

Medications

Include prescriptions, over-the-counter medications and vitamins:

Pharmacy Name(s):

Pharmacy Phone(s):

Do you take oral contraceptives?

Yes No

Do you take any blood thinners?

Yes No

what:

TREATMENT CONSENT

I hereby consent and give my permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such procedures upon me as the doctor deems necessary.

DISCLAIMER: 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.

Signature of Patient, Parent, Guardian or Personal Representative

Date:

Acknowledgment of Notice of Privacy Practices, Policies and Procedures and Permission Form

I have received /had the opportunity to read and understand this practice’s Notice of Privacy Practices written in plain language. The notice was updated on 9/23/2013 and provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice’s legal duties with respect to my information.

I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information, resident at, or controlled by, this practice. If changes to the policy occur, this practice will provide me with a revised Notice of Privacy Practices upon written request.

DISCLAIMER: 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.

Signature of patient or responsible party:

Date:

Acknowledgment of Policies and Procedures

Policies and procedures for CFFAC can be found online at www.flfootandankle.com. By signing below, I testify that I have read, been given the opportunity to read or can request a copy of the policies and procedures at the time of my appointment for my own records. I understand these policies and procedures and will adhere to them.

Also, I authorize the release of any medical information necessary to my insurance company, hospitals or physicians involved in my care. I also authorize payment of medical benefits to Central Florida Foot and Ankle Center and any/all doctors of Central Florida Foot and Ankle Center.

DISCLAIMER: 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.

Signature of patient or responsible party:

Date:

CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS

The Patient hereby consents to the use or disclosure of his/her individually identifiable health information (“protected health information”) by Central Florida Foot and Ankle Center, LLC. in order to carry out treatment, payment, or health care operations. The Patient should review the Practice’s Notice of Privacy Practices for Protected Health Information for a more complete description of the potential uses and disclosures of such information, and the Patient has the right to review such Notice prior to signing this consent form.

Practice reserves for itself the right to change the terms of its Notice of Privacy Practices for Protected Health Information at any time. If the Practice does change the terms of its Notice of Privacy Practices, Patient may obtain a copy of the revised Notice.

Patient retains the right to request that the Practice further restrict how his/her protected health information is used or disclosed to carry out treatment, payment, or health care operations. The Practice is not required to agree to such requested restrictions; however, if the Practice does agree to Patient’s requested restriction(s), such restrictions are then binding on the Practice.

Patient acknowledges and agrees that the Practice may disclose Patient’s protected health information and patient medical record information to the following individuals who are the Patient’s family members, legal representatives, guardians, health care surrogates, or have power of attorney on behalf of the Patient:

****** Note: The names of the individuals must be listed in order for information to be release. Do not leave blank *******

PCP

INSURANCE

REFERRING DOCTOR

FAMILY MEMBER

OTHER

ALL (NO RESTRICTIONS)

If you selected PCP, please specify:

If you selected INSURANCE, please specify:

If you selected REFERRING DOCTOR, please specify:

If you selected OTHER, please specify:

If you selected FAMILY MEMBER, please specify:

The Patient agrees that the Practice may disclose the following types of information contained in the Patient’s medical records (please initial the appropriate categories listed below):

HIV/AIDS Information:

Mental Health Information:

Substance Abuse Information:

Sexually Transmitted Disease Information:

If Patient is under the age of eighteen (18), Pregnancy Information:

All current and past medical conditions/treatment:

These conditions do not apply:

Patient agrees and consents to the Practice releasing information to Patient in the following alternative manners (please initial the appropriate spaces below):

Via Regular Mail with any envelopes being marked personal and confidential and addressed to Patient.

Via telephone, if Patient contacts the Practice and provides the appropriate information (including the Patient’s name, social security number and unique personal identifier).

At all times, Patient retains the right to revoke this Consent. Such revocation must be submitted to the Facility in writing. The revocation shall be effective except to the extent that the Practice has already taken action in reliance on the Consent.

The Practice may refuse to treat Patient if he/she (or an authorized representative) does not sign this Consent Form (except to the extent that the Practice is required by law to treat individuals). If Patient (or authorized representative) signs this Consent Form and then revokes Consent, the Practice has the right to refuse to provide further treatment to Patient as of the time of revocation (except to the extent that the Practice is required by law to treat individuals).

I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY OF THIS FORM AND I AM THE PATIENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS SEALED DOCUMENT VERIFYING CONSENT TO THE ABOVE STATED TERMS.

Date:

Time:

DISCLAIMER: 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.

Signature of Patient (or Authorized Representative*):

Credit Card Authorization Form

Patient Name:

Date:

Guardian’s Name (if applicable):

Email:

Phone number:

Alt #:

The purpose of this form is to authorize Central Florida Foot and Ankle Center to retain a valid credit card number on file for you our patient. If you are paying for copays, deductibles, coinsurance, balances, non-covered services, etc. by card today, the credit card information will be automatically saved to the bank’s secure database at the time of processing.

Your supplied credit card will be charged ONLY under the following circumstances:

1.) If you, as the patient receives services within our office that are non-covered, denied, applied to deductible, or for any reason not paid by your insurance carrier, CFFAC reserves the right to charge the credit card on file for charges that you are responsible for. A message will be sent to the email that you have provided above and you will have 5 business days to respond. If no email address is present or the email is rejected, then you will receive a phone call at the number on file. If no response to email/phone call after 5 business days, the credit card on file will be charged the full balance amount. A receipt will be mailed at your request. If you’re balance is $100 OR LESS, we will reach out to you by phone one time and you will have 24 hours to get back to us. (If you are called on a Friday, we must hear from you by the end of the day on Monday). If we do not hear back from you, your card will be charged the full balance. We highly encourage you to make sure your information on file is accurate at all times.

Patient Initials:

2.) If you, as the patient, miss a scheduled appointment without 24 hour notice to cancel or reschedule, CFFAC reserves the right to charge the credit card listed below, $35.00 for our standard no-show fee. This notice serves as your consent to be charged for all no-shows. A receipt will be mailed upon your request. (As is customary, an automated system for CFFAC will call the phone number on file to remind you of your scheduled appointment. this reminder is usually done 24 hours prior to your scheduled appointment. It is the patient's responsibility to ensure that we have a correct, current telephone number on file)

3.) If you, as the patient, request paper records and do not pick the records up after preparation, CFFAC reserves the right to charge the credit card on file for the fees involved. (Medical Record Policy will be followed: consent must be signed, pt will be notified of the cost prior to preparation, CFFAC will release within 5 business days or receipt of request, pt will be notified once ready)

Other than the conditions mentioned above, under NO circumstance will CFFAC charge your credit card for anything not discussed with you personally. In conjunction with HIPAA regulations, all credit card information will be confidentially kept within your medical chart in our office. Only authorized staff will be able to access this information.

Acknowledged, Agreed, and Accepted:
Having read this form and talked with the physician, and/or staff, my signature below acknowledges that I voluntarily give my authorization and consent to providing the requested information for my credit card to be charged accordingly for the conditions listed above.

*** Please note: If you are paying by CASH, Flex Spending Card or HSA Visa/Mcard today for your copay, deductible, coinsurance, noncovered services, supplies, etc., you will still be required to place a credit card on file that is saved to the bank’s secure database or complete info below. Please be prepared to provide this information to the front desk at check-in prior to being seen***

Select one:

VISA MCARD DISCOVER

Name on Card (name must match signature on file):

Card Number:

Expiration:

Zip:

DISCLAIMER: 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.

Patient Signature:

Date:

Your information will be encrypted.