Patient Information Form

PATIENT INFO: Please print the following information completely.

Date:

Name: Last

First

Middle

Age:

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Date of Birth:

Social Security #:

E-mail

Marital Status:

Occupation

Employer

Employer Address:

State

City

Zip

Emergency Contact

Phone #

Relationship to Patient

SPOUSE'S INFO:

Name

Date of Birth

Address

Home Phone

Employer

Work Phone

*COMPLETE THE FOLLOWING BILLING INFORMATION ONLY IF THE PATIENT IS A MINOR/DEPENDENT.*

*BILLING INFO:

Father's Name

Date of Birth

Address

Phone #

Employer

Work Phone #

Mother's Name

Date of Birth

Address

Phone #

Employer

Work Phone #

PATIENT INSURANCE INFO: Please have ID card available for photocopying.

DO YOU HAVE MEDICAL INSURANCE?

Yes No Medicaid Pending

Insurance Carrier Name:

Policy #:

PHARMACY INFORMATION:

Pharmacy Name

Address:

I hereby authorize release of information necessary to file a claim with my insurance company and request that payment by my medical insurance program be payable to Cardinal Foot & Ankle on any bills for service rendered by them. I understand I am financially responsible for any balance not covered by my insurance carrier. I agree to pay all collection agency (30%) and/or legal fees that may be encountered by Cardinal Foot & Ankle should my account become delinquent, for any reason. I also understand that if the worker's comp carrier and the employer do not pay on any claim, am responsible to pay for services rendered. A copy of this signature is as valid as the original. I agree that all of the above information is complete and accurate.

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.

Patient's Signature

Date

PATIENT'S MEDICAL INFORMATION:

Patient Name

Age

Height

Weight

Family Physician

Date Last Seen

Family Physician Address

Other Physicians

Shoe Size

If referred by another patient or doctor, who?

Briefly describe symptoms/injury

Date of Symptoms/injury

Where did this happen?

Work Home Auto Other

Previous Treatment

If other is select, please specify:

Have you ever had problem with local or general anesthesia?

Yes No

Are you taking prescription medications

Yes No

(f yes, please list):

Add new row

Have you ever had Surgery?

Yes No

(If yes, please list):

Add new row

Do you have any allergies to Food and Drugs?

Yes No

(If yes, list below):

Add new row

Allergies to Latex or Tape?

Yes No

(If yes, please list):

Add new row

Do you smoke?

Yes No

Amount per day

# years

Quit

The above information is complete and accurate to the best of my knowledge. I hereby authorize Cardinal Foot & Ankle to administer treatment and to perform such procedures deemed necessary in the diagnosis and/or treatment of foot and/or ankle conditions, for the patient listed above.

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.

Patient's Signature

Date

Medical Information Release Form

(HIPAA Release Form)

Name:

Date of Birth:

Release of Information

I authorize the release of information including diagnosis, records; examination rendered to me and claims information. This information may be released to:

Add new row

CheckboxInformation is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing.

Messages

Please Call

My home

My Work

My. Cell. Number:

If unable to reach me:

You may leave a detailed message

Please leave a message asking me to return your call

Other:

Notice of Privacy Practices

By signing this, I am authorizing the above as well as acknowledging that I was offered/provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice.

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:

Date :

Witness:

Date :

Your information will be encrypted.