New Patient Forms

Patient Name:

D.O.B.:

Home Address:

City:

State:

Zip Code:

Northern Address:

Home Phone:

Cell Phone:

Business Phone:

Sex:

M F

Social Security #:

Marital Status

S M D Sep W

Email address

Emergency Contact:

Emergency Contact Phone

Primary Insurance:

Secondary Insurance:

Primary Care Physician:

PCP Phone:

Referral:

how did you find out about us?

Race:

White American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander

Language:

English Spanish French Russian Dutch Chinese Japanese Italian

Ethnicity:

Unknown Hispanic or Latino Non-Hispanic/Latino

Family History

Mother living: Mother deceased:

Cause of death:

Age:

Father living: Father deceased:

Cause of death:

Age:

How many children do you have:

Boys

Girls?

Any family history of diabetes?

Yes No

If yes, who?

Any family history of foot problems?

Yes No

If yes, who? What type of foot problems?

Notice of Privacy Act

Patient Contact

We may contact you to provide appointment reminders, treatment information, billing and payment information, or for patient satisfaction surveys.

Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Beaton Podiatry Center Inc dba Advanced Podiatry and Wound Care all insurance benefits, if any, otherwise payable to me for services rendered, I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure payment of my benefits. I authorize the use of this signature on all insurance claim submissions

(INITIALS)

Allowed Uses and Disclosures of Your Medical Information:

Treatment – such as ordering diagnostic test
Payment – such as submitting information to your insurance company
Health Care Operations – such as quality assurance review, coordination of care, eligibility verification.

In addition to the above, your medication information may be used or disclosed for emergency treatment; when we are required by law to treat you, we attempt to obtain consent, and if we are unable to obtain consent due to substantial communication barriers and consent for treatment is implied under the circumstances or we created or received the information in treatment.

You have the right to:

Request a restriction on certain uses and disclosures; however we are not required to agree to any requested restrictions.
Receive confidential communication from us, upon written request.
Inspect and request copies of your medical information.
Request to amend copies of your incorrect or incomplete medical information.
Receive an accounting of any disclosures made, upon written request.
Receive a paper copy of the notice upon request

We are responsible for:

Maintaining the privacy of your medical information.
Providing you this notice.
Abiding by the terms of this notice.
Providing written notice of any change to this notice.

(INITIALS)

Medicare and Insurance Authorization

I request that payment of authorized Medicare or insurance benefits be made to me on my behalf to Beaton Podiatry Center Inc dba Advanced Podiatry and Wound Care for any service furnished to me by that physician. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents; the information needed to determine these benefits or the benefits payable for any related services. I understand my signature request 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 authorized releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician, agency shown, or supplier agrees to accept the charge determination of the Medicare carrier as based upon the charge determination of the Medicare Carrier.

(INITIALS)

Failure to Keep Scheduled Appointments

If you are unable to keep your scheduled appointment, we ask that you please notify our office; at least 24 hours prior to your appointment time. Should you fail to provide proper notice, you will be charged $50.00 for the time that was allotted to you. By not contacting our office to cancel or reschedule your appointment, those in need of a time slot are unfortunately unable to see us. Thank you for your cooperation. I have read the above policies and I understand and agree to these policies.

(INITIALS)

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Printed Name

Signature

Date

Medical History

AIDS/HIV

Yes No

Anemia

Yes No

Bleeding Disorder

Yes No

Cancer

Yes No

Hemophilia

Yes No

Swollen Neck Glands

Yes No

Angina

Yes No

Artificial Heart Valve

Yes No

Chest Pain

Yes No

Circulatory Problem

Yes No

Heart Disease

Yes No

Heart Disease

Yes No

High Blood Pressure

Yes No

Low Blood Pressure

Yes No

Rheumatic Fever

Yes No

Stroke

Yes No

Swelling Ankles/Feet

Yes No

Heart Attack

Yes No

Rheumatoid Arthritis

Yes No

Arthritis

Yes No

Back Problems

Yes No

Gout

Yes No

Asthma

Yes No

Emphysema

Yes No

Respiratory Disease

Yes No

Shortness of Breath

Yes No

Tuberculosis

Yes No

Chemical Dependency

Yes No

Psychiatric Care

Yes No

Diabetes

Yes No

Thyroid Disease

Yes No

Eye Problems

Yes No

Sinus Problems

Yes No

Headaches

Yes No

Phlebitis

Yes No

Vericose Veins

Yes No

Claudication (Leg cramps from walking)

Yes No

Hepatitis or Jaundice

Yes No

Liver Disease

Yes No

Heart Burn

Yes No

Ulcers

Yes No

Weight Loss-unexplained

Yes No

Numbness or tingling (in feet or legs)

Yes No

Seizures

Yes No

Fainting

Yes No

Neurological Problems

Yes No

Venereal Disease

Yes No

Kidney Problems

Yes No

Rash

Yes No

OTHER:

Podiatric History

Describe the chief complaint for which you came to be treated (include foot, ankle, knee, thigh, and hip complaints)

How long has chief complaint been present?

On a scale of 1-10, how bad is the pain?

1 2 3 4 5 6 7 8 9 10

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

Ankle Pain

Yes No

Athlete’s Foot

Yes No

Bunions

Yes No

Corns/Calluses

Yes No

Deformed Toes

Yes No

Fungus Nails

Yes No

Heel Pain

Yes No

Ingrown Toenails

Yes No

Plantar Warts

Yes No

Infection

Yes No

Ulcer/Wound

Yes No

Tired Feet

Yes No

Medical History (cont.)

Cigarette/Tobacco use?

Yes No

(Select One)

Current or Former user?

How much alcohol do you consume?

daily

weekly

monthly

Time smoked:

Surgeries I’ve had:

Medications:

Preferred Pharmacy Name:

Pharmacy Phone#:

Pharmacy Location:

CONSENT

I certify that the above information is correct to the best of my knowledge. I give permission to Dr. William Beaton or Dr. Bella Worman to perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Review of Systems

For new patients, established patients who may be having a new problem, or our patients who haven’t been seen for a while, we need to update our records as to your general medical health. In each area, if you are not having any difficulties, please circle “No.” If you are experiencing any of the symptoms listed, PLEASE SELECT YES. If you have any questions about this, please ask one of the technicians or the doctor.

Constitutional

Weight loss

Yes No

Weight gain

Yes No

Fever

Yes No

Fatigue

Yes No

Dermatologic

Skin infections

Yes No

Psoriasis (skin disease)

Yes No

Spider veins

Yes No

Blisters

Yes No

Moccasin rash (Athlete’s Foot)

Yes No

Macerated webspaces

Yes No

Rash

Yes No

Bleeding

Yes No

Bruising

Yes No

Itching

Yes No

Hypertrophy toenails (thick nails)

Yes No

Foot ulcers

Yes No

Neurologic

Paralysis (loss of ability to move)

Yes No

Stroke

Yes No

Tics

Yes No

Tremors

Yes No

Foot numbness

Yes No

Seizures

Yes No

Tingling feet and/or hands

Yes No

Musculoskeletal

Joint pain

Yes No

Joint swelling

Yes No

Muscle pain

Yes No

Pain after resting

Yes No

Joint disability

Yes No

Weakness

Yes No

Back pain

Yes No

OUR FINANCIAL POLICY

Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require you to sign prior to any treatment.

All patients must complete our information packet and produce all insurance cards and id prior to seeing the doctor

CUSTOM MADE PRODUCTS (SHOES, INSERTS, ORTHOTICS, ETC.) ARE NON REFUNDABLE.

24 Hours notice is required in the event you cannot keep your appointment. If notice is not given in a timely manner there is a mandatory $50.00 no show fee.

ALL returned checks have a $25.00 processing fee applied to the account.

Non insurance patients (self pay) full payment is due at time of service. We accept cash, check, credit card, etc.

Regarding insurance

We may accept assignment of insurance benefits. ALL co pays, coinsurance and deductibles are due at the time of service. In the event that your insurance is not in network you will be considered self pay. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a third party to that contract. Please be aware that some, perhaps all, of the services provided may be non covered services and not considered reasonable under your insurance program.

Usual and customary rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Adult patients

Adult patients are responsible for their portion of payment at the time of service depending of self pay or insurance coverage.

Minor patients

The accompanying parent or guardian is responsible for full payment. For non accompanying minors, non emergency treatment will be denied.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read the financial policy. I understand and agree to this financial policy:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signed Name

Printed Name

Date

Your information will be encrypted.