New Patient Forms

Please correct the errors described below.

Guarantor for Minors:

Emergency Contact:

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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 History

Please list all Medications:

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Dear Patient:

We look forward to seeing you in our office. Thank you for giving us the opportunity to care for your medical needs. In order for us to provide you with the best care possible, we must follow a few guidelines and government regulations.

Office hours: Monday – Thursday: 9:00- 5:00 Friday: 9:00- 12:00 By appointment only

This office works by appointments; however, due the nature of our practice, we sometime experience delays. Please be patient as we give every patient the same careful attention.

By law we are required to have a copy of your Insurance card(s) & Photo ID on file.

Dr. Paradoa and Dr. Caballes use Medical Billing Connection as an outside billing company.

Medicare: Dr. Paradoa/Dr. Caballes are providers for Medicare. Your secondary insurance will be filed as a courtesy. However, if your secondary insurance has not made payment within 90 days of Medicare payment you will be responsible for any remaining balance.

Blue Cross/Blue Shield: Dr. Paradoa/Dr Caballes are providers of BC/BS (Except: Blue Select and Blue Care). Any co-pay or deductible will be due at time of service.

United Health Care: Dr. Paradoa/Dr Caballes are providers of UHC. Any co-pay or deductible will be due at time of service.

Private Insurance: Dr Paradoa/Dr Caballes requires payment at time of service. Your insurance company will be billed in a timely manner for you to receive any reimbursement you are entitled too.

Self-Pay: Dr. Paradoa and Dr. Caballes require payment in full at time of service.

Collections: All unpaid balances will be sent to an outside collection agency or small claims court, after all practice efforts have been exhausted. Any & all small claims & collections cost will be the patient’s responsibility.

Return Check fee: A fee of $35.00 will be charged to any patient account for a returned check.

Appointment No Call/No Show: A fee of $25.00 will be charged to any patient account for a missed appointment.

Fee for completing paperwork: A fee of $35.00 will be collected from the patient at time of service.

X-ray Policy: X-ray CDs are $10.00 each and require a 48-hour notice. If you decide not to pick up the disc your account will be charged for the $10.00 fee regardless.

PHOTOGRAPH CONSENT FORM

I give consent to Dr. Paradoa and/or Dr. Caballes and staff for any photography that may need to be obtained during my treatment. I understand this information will be kept in my chart.

I, the undersigned agree to all above, I also agree to be responsible for any charges incurred by me or not payable by my insurance company. I also agree to be responsible for any legal fees and/or court costs incurred as a result of my failure to pay for services rendered.

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.

Medical Records Release - Authorization for Use or Disclosure of Protected Health Information

Please send the requested records to: Address: 3735 11th Circle Suite 201 Vero Beach, Florida 32960 Phone: (772) 299-7009 Fax: (772)562-7138

The information requested may be used for purposes of my continued health care. I understand that after the custodian of records discloses my health care information, it may no longer be protected by the federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign the authorization. my refusal to sign will not affect my ability to obtain treatment; receive payment or eligibility for benefits unless allowed by law. By signing below, I represent and warrant that I have the authority to sign this document and authorize the use and disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

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 RELEASE PROTECTED HEALTH INFORMATION

By authorizing the listed persons below, they will have access to any and all of my health information, up to and including HIV, drug and alcohol and psychiatric records.

Amberly Paradoa, DPM/Timothy Caballes, DPM is permitted to share my medical information with them including test results, appointment reminders and information disclosed during office visits.

Persons (other than Physicians) authorized to receive my medical information:

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I understand and direct that this authorization will remain in effect until it is revoked by me in writing.

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.

HIPAA: This organization complies with all HIPAA and other federal privacy regulations. A notice of privacy is available upon request. I acknowledge by signature below that I have been made aware of my right to review or obtain a copy of the policies. NOTICE OF HEALTHCARE INFORMATION: All patient records remain the property of this practice. Records are centralized and may be accessed by the medical providers or employees as a necessary function of their role within the organization. This organization does not release patient records unless necessary for purposes of medical treatment, obtaining payment or supporting the day-to-day health care operations of the practice. Patient signature below provides the practice your consent to use and disclose my health information to the above statement.

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 for Recurring Credit Card Charges

At Advanced Foot & Ankle of Indian River, we require keeping your credit or debit card on file as a convenient method of payment for the portion of services that your insurance doesn’t cover, but for which you are liable.

Your credit card information is kept confidential and secure.

Copays and deductibles will be charged the day of service. Additional payments not covered by insurance are processed only after the claim has been filed and processed by your insurer, and the insurance portion of the claim has been paid and posted to the account. The charge will be made under the name Amberly C. Paradoa, DPM. You agree that no prior notification is necessary unless the amount billed each time exceeds $100.00, in which case you will receive notification in advance.

I authorize Advanced Foot & Ankle of Indian River (Amberly C. Paradoa, DPM) to charge this credit card for professional services and associated charges as agreed below.

Self-pay for session or payment for session not covered due to deductible,

Charge for cancellation without 24 hours’ notice: $ 25.00,

Other charges:

I understand that this authorization will remain in effect until I cancel with a 30-day written notice to Advanced Foot & Ankle of Indian River.

X- RAY POLICY

In order to better serve our patients we require 48 hours notice for all requests for X-Ray CD's.

X-RAY CD's are $10.00 Each

If you request a Disc to be made and fail to pick it up or decide it is no longer needed your account will be charged and you will be billed for the amount.

If you are in agreement with the information provided above, Please sign your acceptance to abide by this policy.

PATIENT’S CONSENT/HIPAA

(for use and disclosure of protected health information to carry out treatment, payment or health care operations)

I agree to allow Dr. Paradoa/Dr Caballes to use or disclose the protected health care information of the listed patient to carry out treatment, payment or health care operations. I have been informed of the Privacy Notice. The notice is a more complete description of the uses and disclosures of protected health information that may be made, and of my rights with respect to protected health information

  • I have received a copy of the Privacy Notice.
  • I understand that I have the right to review the notice before signing this consent.
  • I understand that the terms of the Privacy Notice may change, and that I have the right to request a revised copy of the Notice.

I understand that I have the right to request a restriction on how protected health information is used or disclosed in order for Dr. Paradoa/Dr Caballes to carry out treatment, payment and health care operations. Further, I understand that this request for restriction must be in writing and if the health care provider agrees to the restriction, the restriction is binding. However, the health care provider is not required to agree to the requested restriction. I also understand that the office may call my home to confirm information, and will mail statements to the address I have listed, which is part of the health care operations of Amberly Paradoa DPM, FACFAS.

I understand that I have the right to revoke this consent at any time. The revocation must be in writing.

Patient Portal

Join the new generation of patients who are taking a more active role in managing their health and wellness. Access your personal medical records, communicate with your doctors via secure online messaging, and make more informed decisions about your health!

To sign up for a portal account today, please give our receptionist your email address so they may send you an invite.

1. What is a Patient portal?

A patient portal is a secure online website that gives patients convenient, 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can view and update health information such as:

  • Insurance Information and demographics
  • View Current prescription list
  • Request prescription refills
  • Request appointments or cancel a current appointment
  • Update your contacts, emergency contacts, and providers
  • Access visit notes once they are signed off by the providers
  • View Care plans
  • Review lab results after seeing the physician
  • Send a text message to practice
  • View vital signs log

With your patient portal, you can be in control of your health and care. Patient portals can also save your time, help you communicate with your doctor, and support care between visits.

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