New Patient Paperwork

PATIENT INFORMATION

Date:

Birth Date:

Sex:

M F

Patient Name:

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

Have you ever been to a Podiatrist before:

Yes No

If yes, please list.Name :

Last Visit:

Was Surgery done:

Reason for visit today:

How long have you had the problem:

Describe your pain:

Rate your pain level (1-10):

Are you a diabetic:

Yes No

Endocrinologist:

Last Visit:

A1C reading at that visit:

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)

NONE APPLY

(check if applicable)

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:

Are you currently PREGNANT or is there a chance you could be pregnant?

Last Menstrual Date:

Family Physician:

Date of last visit:

List of Surgeries you have had:

Allergies (write NONE if no known drug allergies):

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*):

Please print name

Your information will be encrypted.