Patient Information

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INSURANCE INFORMATION

SOCIAL HISTORY

FAMILY HISTORY: PLEASE CHECK M for MOTHER OR F for FATHER

YOUR MEDICAL HISTORY

PLEASE LIST ALL MEDICATIONSYOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTERMEDS AND HERBAL SUPPLEMENTS): PLEASE BRING A LIST WITH YOU

PLEASE LIST ALL PRIOR SURGERIES

PLEASE LIST ALL PRIOR HOSPITALIZATIONS

HAVE YOU EVER HAD ANY OF THE FOLLOWING PROBLEMS?

CURRENT PROBLEM

Where is the pain/problem located? Please indicate on the pictures below.

TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONSON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDINGINCORRECTINFORMATIONCAN BE DANGEROUS TO MY HEALTH.I UNDERSTANDTHAT IT IS MY RESPONSIBILITYTO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICALSTATUS.

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

Welcome and thank you for choosing Foot First Podiatry for your Podiatric foot care needs. In our effort to provide personalized patient care in the most efficient and economical manner possible, we ask that you take a moment to read our Financial Policy, fill out the demographic health history forms for your medical file. If at any time you have a question regarding our office policies do not hesitate to contact us and we will be happy to help you.

Your clear understanding of our Financial Policy is important to our professional relationship. We are a Medicare provider and also a provider for most PPO and HMO plans in our area. It is your responsibility to make sure we are on your insurance plan. If your insurance requires a referral or prior authorization, it is your responsibility to make sure that it is in place prior to your appointment. We will be glad to assist you if you need help.

Patient Billing

Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you, if you have an unmet deductible we pre-collect 50% of the charges incurred that your insurance will apply towards your deductible.

All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.

Complete payment for all podiatry soft goods, medical products and supplies are due at the time they are dispensed.

Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check.

You must inform the office of all-insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied.

For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.

There are certain elective surgical procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.

Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office

There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee.

Appointment Cancellation Policy

A 24-hour notice is requested for cancellations of appointments. If you fail to show for an appointment you personally may be charged a $25.00 no-show fee. We will try to accommodate you in rescheduling your appointment as soon as possible.

Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.

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.