Health History Form

Pharmacy Information:

Primary Care Information:

Medical Information

Consent for Treatment

With my signature, I request and consent to receive medical treatment that us deemed necessary for my foot health. i understand that Beverly Podiatry Podiatrists will proceed with routine diagnostic procedures and treatment upon council, discussion and mutual agreement.

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.

BEVERLY PODIATRY AUTHORIZATIONS SIGNATURE PAGE*/**

AUTHORIZATION TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS

By signing below, I authorize Beverly Podiatry to release of any medical or other information necessary to process my insurance claims). I also authorize payment of my insurance and/or Government Benefits be made directly to Beverly Podiatry which include but not limited to Timothy J. Tobin, D.P.M., Lawrence E. McGinness, D.P.M. Rebecca R. Calder, D.P.M. and Matthew A. Peter, D.P.M. whom accept assignments.

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.

NON-COVERED SERVICES WAIVER/NOTICE OF FINANCIAL LIABILITY

I accept full financial liability for all items or services determined by my health care service plan which are deemed patient's responsibility. Services not specified as being covered in patient's contract, charges that occur because of missing referrals, deductibles, copays, coinsurance, or because the patient is considered out of network. I understand and agree that it is my responsibility and obligation to obtain a referral if required, and to follow up with my Primary Care Physician Referral Department to be sure my referral has been sent in a timely manner.

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.

NOTICE OF HEALTH PRIVACY PRACTICES

I acknowledge that I have been offered and understand Beverly Podiatry's NOTICE OF PRIVACY PRACTICES. This notice describes how we use/disclose your healthcare information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected information. I understand that this Notice of Privacy Practices is available should I wish to take one home with me.

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.

MEDICAL HISTORY AUTHORIZATION

By signing below, I authorize Beverly Podiatry to have access to my medical records which includes my medical history and medications, as required for treatment and documentation.

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.

*If minor, please have parent/guardian sign.
**It is policy to require all 4 signatures to be seen here at Beverly Podiatry.