New Patient Forms

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Patient Information

Referred to Office by:

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Insurance Information

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.

Medical History Form

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

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

PLEASE ANSWER EACH OF THE FOLLOWING

Family 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 $25.00 fee charged to your account if you do not give 24 hours advance notice. If you are more that 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.

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.

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.

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.

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.

*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:

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.

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