New Patient Forms

Patient Information

Last Name

First Name

Date of Birth

Age

Address

City

State

Zip

SS #

Spouse, Parent or Guardian's name

Home Phone

Cell Phone

Work Phone

Employer

Employer Phone

Please Check the Appropriate Boxes

Single Married Widowed Other

Sex

Male Female

Preferred Language

Race

Hispanic

Yes No

Emergency Contact

Emergency Contact Phone

Referred to Office by:

Dr.

Please Specify

Friend/Family

Please Specify

Do Not Have Email Wish Not to Disclose

Insurance Information

Primary Insurance

Policy #

Group #

Insured Name

Insured Date of Birth

Insured Employer

Insured Employer Phone

Insured Employer Address

City

State

Zip

Patient's Relationship to Insured

Self Spouse Child Other

If Other, please specify:

Secondary Insurance

Policy #

Group #

Insured Name

Insured Date of Birth

Insured Employer

Insured Employer Phone

Insured Employer Address

City

State

Zip

Patient's Relationship to Insured

Self Spouse Child Other

If Other, please specify:

AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

I hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor. I agree to pay any balance not covered by the approved medical insurance. If for any reason the account should become delinquent, I agree to pay any interest charges, collection costs, and reasonable legal fees.

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

Date

Medical History Form

Patient Name

Date

Reason for office visit

Duration of problem

Your height

Your weight

ALLERGIES (CHECK ALL KNOWN ALLERGIES OR REACTIONS TO DRUGS/MEDICATIONS)

Penicillin

Sulfa

Local Anesthetic

Iodine

Codeine

Tape/Adhesive

Aspirin

Other Antibiotics

MEDICATIONS (PLEASE LIST ALL CURRENT MEDICATIONS YOU ARE TAKING – INCLUDING PRESCRIPTION AND NON-PRESCRIPTION/OVER THE COUNTER)

Medication

Dose

Add new row

What is your preferred pharmacy?

SURGERIES (PLEASE LIST ALL SURGERIES YOU HAVE HAD)

WHAT PREVIOUS TREATMENT HAVE YOU HAD ON YOUR FOOT/ANKLE? (PLEASE CHECK ALL THAT APPLY)

Surgery

Orthotics

Cortisone Shots

Other

If other, please specify

HAVE YOU HAD OR DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING?
(PLEASE CHECK THE CORRECT RESPONSE AND EXAMPLE IF APPLICABLE)

Anemia

Yes No

Arthritis/Rheumatism

Yes No

Artificial Joints (Hip, Knee, etc)

Yes No

Bleeding Problems

Yes No

Cancer

Yes No

Circulation Problems

Yes No

Diabetes (Type 1/Type 2)

Yes No

Fainting Problems

Yes No

Gout

Yes No

Heart Problems (Attack, Murmur, Disease, etc.)

Yes No

Hepatitis (A, B, or C)

Yes No

High Blood Pressure

Yes No

Kidney Problems

Yes No

Liver Disease or Problems

Yes No

Lung Problems

Yes No

Neurological Disorder

Yes No

Phlebitis

Yes No

Seizures

Yes No

Stomach Problems (Reflux, Heartburn, etc.)

Yes No

Stroke

Yes No

Thyroid

Yes No

Transfusions

Yes No

Ulcers

Yes No

PLEASE ANSWER EACH OF THE FOLLOWING

Do you smoke or use tobacco?

Yes No Previously, but quit

If yes, packs or amount per day

Do you drink alcohol?

Yes No

If yes, how often?

Daily Occasionally Rarely

Do you use drugs?

Yes No

If yes, type of drug and frequency

If you are a woman, are you pregnant?

Yes No

Prior hospitalizations?

Yes No

If yes, please explain

Family Medical History

Family Physician

Name of Primary Physician

Physician's Address

City

State

Zip

Physician's Phone Number

Date of Last Visit with Physician

Important Office Information

Welcome to Advanced Foot and Ankle Centers. We are committed to providing you with the best care possible. Your understating of our Office Policy is very important to us. Please read the following information, sign and return it to us. We will be happy to discuss any questions that you may have.

INSURANCE AND CLAIM SUBMISSION: We participate with many various insurance companies. As a courtesy, we will bill most insurance companies for our patients. Please understand that your insurance coverage is an agreement between you and your insurance company. Knowing your insurance benefits is your responsibility.

PROOF OF INSURANCE: All patients are required to compete and/or update our patient information form. You will be asked to verify your address, phone and insurance information. If you cannot provide up-to-date health insurance information, you will be responsible for payment in full.

CO-PAYS AND DEDUCTIBLES: Co-pays and deductibles are the out of pocket expenses you are responsible for. Co-pays are required for all office visits, including follow-up examinations. Deductibles are determined by your policy with your insurance carrier. We collect office visit co-pays on the day of your visit. We can’t write off co-pays and deductibles because we have signed a contract with the insurance carrier that stipulates we collect co-pays and deductibles from the patient.

YOUR ACCOUNT: Statements are billed monthly. Payment Plans are available based on balance and account history. Accounts that are 90 days past due with no payment history will be turned over to a collection agency. Personal checks that are returned for non-sufficient funds are subject to a $25.00 administrative fee.

MISSED APPOINTMENTS: There will be a No Show fee charged to your account if you do not give 24 hours advance notice. Fees are as follows: Office Visit, Nurse Visit $25.00, Minor in office surgery $50.00, Major in office surgery $100.00 and Hospital surgery $250.00. If you are more then 15 minutes late, without notification, your appointment will be changed to a no show and you will be rescheduled. After 3 no show appointments you will be discharged from the practice

FORMS: There is charge for the physician to fill out forms. Two pages or less is $10.00. Three pages or more is $25.00. This is due at the time the form is picked up.

I have read and understand the office policy and agree to abide by its guidelines.

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.

Responsible Party Signature

Relationship

Date

Summary of Notice of Privacy Practices

The Notice of Privacy Practices contains a detailed description of how our office will protect your health information, your rights as a patient, and our common practices in dealing with patient health information. The following material is a summary of that notice and is provided to asset you in understanding it’s contents. Please note that a complete copy is available at the reception deck.

Uses and Disclosures of Health Information.

We will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose our health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to your by us or other health care providers. Finally, we may disclose your health information for certain limited operation activities such as quality assessment, licensing, accreditation, and training of students.

Uses and Disclosures Based on Your Authorization.

With the exception of the following circumstances, we may not use or disclose your health information without your written authorization:

For purposes of public health and safety
For certain limited research purposes
For government authorities to prevent child abuse or domestic violence
For government agencies for purposes of their audits, investigations, and other oversight activities
For law enforcement authorities to protect public safety or to assist in apprehending criminal offenders
For the FDA to report product defects or incidents
When required by court orders, search warrants, subpoenas, and as otherwise required by law

Patient Rights.

As a patient, you have the following rights:

To have access to your health information
To request restrictions as to how your health information is used or disclosed
To receive notice of our privacy practices

Acknowledgement of Notice of Privacy Practices

I acknowledge that I have received Advanced Foot and Ankle Centers’ Notice of Privacy Practices. I have had full opportunity to read and considered the contents of the Notice of Privacy Practices.

Patient Name

Relationship to Patient

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

Date

PRESCRIPTION HISTORY CONSENT

I agree Advanced Foot and Ankle Centers may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes.

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

Date

Parent/Guardian Signature (If patient is a minor)

PLEASE READ AND SIGN THIS RELEASE OF INFORMATION SECTION

authorize Advanced Foot & Ankle Centers to release and/or discuss information relevant to my care to the following individuals:

Name and relationship

Office Use Only

I attempted to obtain the patient’s signature in acknowledgement of the Notice of Privacy Practices, but was unable to do so.

Date

Initials

Reason

Your information will be encrypted.

New Patient Forms

Patient Information

Insurance Information

AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

Medical History Form

Family Physician

Important Office Information

Summary of Notice of Privacy Practices

Uses and Disclosures of Health Information.

Uses and Disclosures Based on Your Authorization.

Patient Rights.

Acknowledgement of Notice of Privacy Practices

PRESCRIPTION HISTORY CONSENT

*PLEASE READ AND SIGN THIS RELEASE OF INFORMATION SECTION*

Office Use Only

PLEASE READ AND SIGN THIS RELEASE OF INFORMATION SECTION