Patient Information Sheet

PATIENT INFORMATION SHEET

Date:

First Name:

MI:

Last Name:

Address:

City/State:

Zip:

Birthdate:

Age:

Gender:

Female Male

Civil Status:

Single Married Other

Phone:

Work Phone:

Cell Phone:

E-mail:

Place of Employment:

In Case of Emergency, Contact:

Phone:

Relationship to you:

If you are not responsible for the patient bill, who will be? If insured by parent/spouse, include SS# and DOB.

Spouse/Parent/Other:

Last Name:

First Name:

Address:

City/State:

Zip:

Phone:

SS#:

Birthdate:

Primary Care Physician:

Who referred you to our office?

PATIENT'S AUTHORIZATION

I hereby authorize the physicians of the Diabetic Foot and Wound Care Center, SUSAN E. HOLIBAUGH, DPM and Megan DeMara, DPM, to diagnose and treat my condition as deemed medically necessary. I authorize release of any medical and/or insurance necessary to process my claims for services rendered by the physician of the DIABETIC FOOT AND WOUND CARE CENTER. I also authorize my insurance carriers to direct payment for services rendered to the DIABETIC FOOT AND WOUND CARE CENTER.

I understand that I am ultimately responsible for any charges regardless of my insurance. THE DIABETIC FOOT AND WOUND CARE CENTER will make all reasonable attempts to obtain payment from my insurance company. However, if the services provided are not a covered benefit by my insurance carrier, I realize that I am responsible for the charges.

Disclaimer: 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 of Patient or Responsible Party:

Date:

Sex:

Height:

Weight:

Have there been any changes in your health in the last year?

Date of last physical examination:

Name and address of your family physician:

Are you taking any medications? (If you have a list, please give it to the receptionist or assistant and we will make a copy; otherwise, please list.)

Are you allergic to any medications? If so, please list:

Have you ever had a local anesthetic either at the dental office or in the emergency room?

Did you have any adverse reactions to it?

If so, what?

What type of problem are you having with your foot?

Disclaimer: 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 of Patient:

Health Questionnaire Update FORM

Patient Name:

DOB:

What Pharmacy do you use?

SOCIAL HISTORY:

Do you smoke?

Yes No

Did you ever smoke?

Yes No

Do you drink alcohol?

Yes No

Are you:

Married Single Widowed Divorced

Do you use recreational drugs?

Yes No

Are you:

Employed Retired Disabled

FAMILY HISTORY:

Are your parents Iiving?

Yes No

If no, what did they die from?

Please list the surgeries you have had:

Do you have any artificial joints? If yes, please list.

SUMMARY OF NOTICE OF PRIVACY PRACTICES

The attached 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.

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

USES AND DISCLOSURES BASED ON YOUR AUTHORIZATION
Except as stated in more detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization.

USES AND DISCLOSURES NOT REQUIRING YOUR AUTHORIZATION
In the following circumstances, we may disclose your health information without your written authorization: To family members or close friends who are involved in your health care; For certain limited research purposes; For purposes of public health and safety; To Government agencies for purposes of their audits, investigations, and other oversight activities; To Government authorities to prevent child abuse or domestic violence; To the FDA to report product defects or incidents; To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders; When required by court orders, search warrants, subpoenas, and as otherwise required by the law.

PATIENT RIGHTS: As our patient, you have the following rights:

To have access to and/or a copy of your health information; To receive an accounting of certain disclosures we have made of your health information; To request restrictions as to how your health information is used or disclosed; To request that we communicate with you in confidence; To request that we amend your health information; To receive notice of our privacy practices.

I acknowledge that I was 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.

Patient Name (Signature):

Date:

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.