Este es un registro confidencial y se mantendrá en el consultorio de su médico. La información contenida en este formulario no se suelta sin su permiso.
Padres de Paciente / Tutor: (Si es menor de 18*)
En caso que si, por favor escriba:
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Por favor, indique cuáles son los problemas del pie que usted tiene ahora:
Por favor liste todas sus hospitalizaciones y cirugías con las fechas:
He leído las preguntas anteriores y las he contestado a lo mejor de mi conocimiento. Autorizo Long Island Foot Care, P.C./Dr. Emilio Goez, el personal y los asociados para examinar y me traten. También autorizo la divulgación de cualquier información médica necesaria para procesar reclamaciones de seguros médicos. En el caso de mi póliza de seguro de salud no pagar o cubrir mis gastos de cuidado, entiendo que soy responsable del pago.
AVISO LEGAL: Al escribir su nombre a continuación, firma este formulario electrónicamente. Acepta que su firma electrónica es el equivalente legal de su firma manual en esta solicitud.
authorize Dr. Emilio A. Goez, Dr. Nicole Castillo, Dr. Marcin Romanczyk. Dr. Anthony Goez to mark the section "ENROLLEE'S OR AUTHORIZED PERSON'S SIGNATURE" with the notation "SIGNATURE ON FILE".
This section authorizes:
This authorization will remain in force until terminated in writing by the enrollee.
I understand and agree that health and accident policies are an agreement between an insurance carrier and me. In case of denial or termination of benefits, I, the undersigned, understand that I am responsible for payment in full for services rendered.
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 so chose) and understood the Notice.
Patient medication history is a list of prescription medicines that our practice providers, or other providers, have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice electronic medical record system (EHR/EMR) and becomes part of your personal medical record. Medication history is especially important in helping healthcare providers treat your symptoms and/or illness properly and in avoiding potentially dangerous drug interactions.
It is especially important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Also, over-the-counter drugs, supplements, or herbal remedies that patients take on their own may not be included.
By signing this consent form, you are giving your healthcare provider permission to collect and giving your pharmacy and your health insurer permission to disclose information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.
I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.
We now provide our patients with the option to participate in our online patient communication system. These features include appointment confirmation via email Text Message.
I consent receiving appointment confirmation via:
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