New Patient Packet

Patient Information

Patient's Name

Preferred Name

Birth Date

Marital status

Married Single Widowed Divorced

Sex

Male Female

Home Phone

Cell Phone

Consent to text

Yes No

Work Phone

Home address

City

State

Zip

How did you hear about us?

Social Security Number

Language

Race (optional)

Ethnicity (optional)

Employer

Name

Street

City

Preferred Pharmacy

Name

Street

City

Phone

Is the patient in a skilled facility or enrolled in hospice?

Yes No

Primary Care Provider

Referring Provider

In Case of Emergency

Name of contact

Relationship to patient

Phone

Can CCFAAS release medical information to this person?

Yes No

Initials

As a courtesy, Central Coast Foot & Ankle Specialists (CCFAAS), verifies Podiatry benefits with your insurance company and we will be happy to bill them. Please provide your insurance information to the front office staff. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.

It is the policy of CCFAAS that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. Our office will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.

Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.

Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment. We highly recommend you also contact your insurance carrier and check into your coverage for Podiatry services. Do not assume that you will not owe anything if you have more than one insurance policy.

I request that payment of authorized insurance or Medicare benefits be made to me or on my behalf to Central Coast Foot & Ankle Specialists. I understand that I am ultimately responsible for payments on my account. A $35. NSF charge will be applied to all accounts with a returned check. Your signature is necessary for us to submit any claim and to insure payment of services rendered on your behalf.

If you have no insurance, payment is required at the time of service.

I HAVE READ THE ABOVE AGREEMENT AND AGREE TO THE TERMS AND CONDITIONS AS SET FORTH BY CENTRAL COAST FOOT & ANKLE SPECIALISTS. Thank you.

Print Name

Signature of Patient/Responsible party

Date

Thank you for choosing us as your provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with but you have copays or deductibles, payment in full is expected at each visit. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.
Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.
Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.
Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.
Late appointments. Our policy is to reschedule your appointment if you are more than 10 minutes late. You will be subject to a missed appointment fee ($25). Please help us to serve our patients timely by showing up to your appointment on time.
Missed appointments. Our policy is to charge for missed appointments ($25) not canceled with at least 24 hours’ notice. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.
Surgery cancellations. Our policy is to charge for any surgeries cancellations ($250) once appointment is made. Your request for surgery requires multiple person hours to coordinate. These charges will be your responsibility and billed directly to you.
Paperwork. Our policy is to charge for any paperwork ($25) that needs to be filled out by the physician or office staff. This fee is to be paid up front when paperwork is dropped off or called in to be filed online. The charges will be your responsibility and billed directly to you.

By signing below, you also understand that any charges not covered by your insurance for durable medical equipment (DME) will be your responsibility and billed directly to you.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

HIPAA Privacy Rule

In accordance with the HIPAA Privacy Rule, when Protected Health Information (PHI) is to be used or disclosed for purposes other than treatment, payment, or health care operations, the Facility will use and disclose it only pursuant to a valid, written authorization, unless such use or disclosure is otherwise permitted or required by law. Use or disclosure pursuant to an authorization will be consistent with the terms of such authorization.

I have read and understand the payment policy and agree to abide by its guidelines:

Signature of Patient / Responsible party

Date

Name

Appointment Date

Height Feet

Height Inches

Reason for visit

Right

Left

Foot

Toes

Heel

Ankle

Explain

Medication Allergies

Reaction

Nausea

Vomiting

Rash

Respiratory Distress

Other

No Known Allergies

Medication Allergies

Reaction

Nausea

Vomiting

Rash

Respiratory Distress

Other

No Known Allergies

Current Medications and dosing: (or provide list)

Vaccinations:

Pneumonia

Yes No

Date

Tetanus

Yes No

Date

Flu

Yes No

Date

Past and Current Medical History: (please include approximate date of diagnosis)

ADHD

Yes No

AIDS / HIV

Yes No

Alzheimer's Dementia

Yes No

Anemia

Yes No

Anxiety

Yes No

Asthma

Yes No

Atrial Fibrillation

Yes No

Bipolar Disorder

Yes No

Cancer

Yes No

Type:

Date

Cirrhosis of Liver

Yes No

Congestive Heart Failure

Yes No

COPD

Yes No

Dementia

Yes No

Depression

Yes No

Diabetes

Yes No

Type:

Date

Dry Skin

Yes No

DVT / Pulmonary Embolism

Yes No

Gout

Yes No

Heart Attack

Yes No

Date

Heart Murmur

Yes No

Hepatitis

Yes No

Type:

Active

Hypertension

Yes No

Jaundice

Yes No

Kidney Disease

Yes No

Stage

Lupus

Yes No

Migraines

Yes No

Multiple Sclerosis

Yes No

Numbness

Yes No

Osteoarthritis

Yes No

Osteopenia

Yes No

Pacemaker

Yes No

Date

Parkinson's Disease

Yes No

Poor Balance

Yes No

Psoriasis

Yes No

Psoriatic Arthritis

Yes No

Rheumatoid Arthritis

Yes No

Schizophrenia

Yes No

Scleroderma

Yes No

Sjogren's Syndrome

Yes No

Stroke

Yes No

Date

Seizures

Yes No

Last Episode

Thyroid Disorder

Yes No

Family History

Cancer

Yes No

Who

Father

Mother

Brother

Sister

Type

Diabetes

Yes No

Who

Father

Mother

Brother

Sister

Hypertension

Yes No

Who

Father

Mother

Brother

Sister

Stroke

Yes No

Who

Father

Mother

Brother

Sister

Social History: (please choose and include details indicated)

Smoking

Current Former

PPD

Years of use

Stop Date

Alcohol

Occasional Moderate Heavy

Drinks per week

Years of use

Illicit Drugs

Former Current

Type(s)

Last used

Employer

Occupation

Surgeries: (please include dates)

Patient Opioid Agreement Contract

This is an agreement between

and Dr. Julie Chatigny, DPM / Dr. Darrel Richards, DPM (Central Coast Foot & Ankle Specialists) concerning the use of opioid analgesics (narcotic pain-killers) for the treatment of my post-operative course. I understand and voluntarily agree that (initial each statement after reviewing):

I understand that opioid analgesics are strong medications for pain relief and I have been informed of the risks and side effects involved with taking them.

In particular, I understand that opioid analgesics could cause physical dependence. If I suddenly stop or decrease the medication, I could have withdrawal symptoms (flu-like syndrome such as nausea, vomiting, diarrhea, aches, sweats, chills) that may occur within 24/48 hours of the last dose. I understand that opioid withdrawal is quite uncomfortable, but not a life-threatening condition.

I understand that if I am pregnant or become pregnant while taking these opioid medications, my child would be physically dependent on the opioids and withdrawal can be life-threatening for a baby.

Overdose on this medication may cause death by stopping my breathing; this can be reversed by emergency medical personnel if they know I have taken narcotic pain-killers.

Opioid analgesics cause drowsiness, sedation, or dizziness.

I understand that I must not drive a motor vehicle or operate machinery that could put my life or someone else’s life in jeopardy.

I understand it is my responsibility to inform the doctor of any and all side effects I have from this medication.

I agree to take this medication as prescribed and not to change the amount or frequency of the medication without discussing it with the prescribing doctor. Running out early, needing early refills, escalating doses without permission, and losing prescriptions may be signs of misuse of the medication and may be reasons for the doctor to discontinue prescribing to me.

I agree to keep my medication in a safe and secure place. Lost, stolen, or damaged medication will not be replaced.

I agree not to drink alcohol or take other mood-altering drugs while I am taking opioid analgesic medication.

I agree not to sell, lend, or in any way give my medication to any other person.

I will treat the staff at the office respectfully at all times. I understand that if I am disrespectful to staff or disrupt the care of other patients, my treatment will be stopped.

I understand that there is a small risk that opioid addiction could occur. This means that I might become psychologically dependent on the medication, using it to change my mood or get high, or be unable to control my use of it. People with past history of alcohol or drug abuse problems are more susceptible to addiction. If this occurs, the medication will be discontinued and I will be referred to a drug treatment program for help with this problem.

I agree that I will attend all required follow-up visits with the doctor to monitor my recovery/condition and I understand that failure to do so will result in discontinuation of this treatment. I also agree to participate in other chronic pain treatment modalities recommended by my doctor.

I understand the common side effects of opioid therapy include nausea, constipation, sweating, itching, dry mouth, and rash.

I agree that the opioids will be prescribed by only one doctor and I agree to fill my prescriptions at only one pharmacy. I agree not to take any pain medication or mind-altering medication prescribed by any other physician without first discussing it with the above-named doctor. I give permission for the doctor to verify that I am not seeing other doctors for opioid medication or going to other pharmacies.

Pharmacy

Name

Location

Number

Drowsiness may occur when starting opioid therapy when increasing the dosage. I agree to refrain from driving a motor vehicle or operating dangerous machinery until such drowsiness disappears.

I understand that the use of any mood-modifying substance, such as tranquilizers, sleeping pills, alcohol or illicit drugs (such as cannabis, cocaine, heroin, or hallucinogens) can cause adverse effects or interfere with opioid therapy. Therefore, I agree to refrain from the use of all these substances without first discussing it with my physicians.

I also understand that I may be discharged from care if I use any of these substances. If I use medicinal marijuana then I will not drive under the influence of cannabis. I agree not to provide my prescribed medication to any other person at the result in being discharged as a patient. I also understand that lost or stolen medications will not be refilled until the proper due date. If I break this agreement, my physician reserves the right to stop prescribing opioid medications for me and may discharge me from care. I hereby agree that my physician has the authority to disclose the prescribing information in my patient file to other health care professionals when it is deemed medically necessary in the physician’s judgment.

Patient Signature / Responsible Party

Date

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