NEW PATIENT FORMS

Dear Patient,

Thank you for choosing Medford Foot and Ankle Clinic for your podiatric care. Enclosed are the registration and medical history forms. Please complete all forms online at least one day prior to your appointment. If all forms are complete, please check in 15 minutes prior to your scheduled appointment time. We have included a checklist of items you will need to bring to your appointment:

Your insurance card (we will ask to copy your insurance cards and personal ID such as a driver’s license)
Any prior x-rays of your feet taken in the last 12 months. If you do not have x-rays to bring, recently obtained x-rays were non-weightbearing, or if the provider is unable to view them, new weightbearing images will likely be ordered during your appointment.
If you are diabetic, Please bring or have faxed to our office a copy of your most recent HBA1C lab. (Available from your primary care doctor)

If you have Allcare, Triwest or Workers Comp please secure a referral prior to scheduling an appointment.

The Medford Foot &Ankle Clinic is located at 713 Golf View Drive, Medford, Oregon. From Interstate 5 take Exit 27, go north on Highland, then East on Barnett Road (towards Rogue Regional Medical Center), turn right on Golf View Drive (Approximately ¼ mile past Rogue Regional Medical Center). The clinic is the second building on the left.

We look forward to meeting you.
The staff at Medford Foot & Ankle Clinic.

Please complete all questions

PATIENT INFORMATION

LAST NAME

FIRST NAME

MIDDLE

DATE

ADDRESS

CITY

STATE

ZIP

MAILING ADDRESS

HOME PHONE

CELL PHONE

SOCIAL SEC. NO.

DATE OF BIRTH

AGE

PATIENT’S EMPLOYER

POSITION

OCCUPATION

For access to your “Health Vault” an email address is required

PERSONAL PHYSICIAN

DATE LAST SEEN

PREFERRED METHODS OF CONTACT

PHONE

E-MAIL

MAIL

SMS / TEXT

PRIMARY LANGUAGE:

RACE:

WHITE

BLACK

ASIAN

AMER. INDIAN

PACIFIC ISLANDER

NOT SPECIFIED

EMERGENCY CONTACT

NAME

RELATIONSHIP

ADDRESS

HOME PHONE

PERSON RESPONSIBLE FOR BILL

(IF OTHER THAN ABOVE OR IF PATIENT IS A MINOR)

NAME

RELATIONSHIP

ADDRESS

CITY

STATE

ZIP

HOME PHONE

WORK PHONE

INSURANCE INFORMATION

PRIMARY INSUR. CO.

INSURED NAME

INSURED BIRTHDATE

RELATIONSHIP TO PATIENT

ID#

GROUP#

SECONDARY INSUR. CO.

INSURED NAME

INSURED BIRTHDATE

RELATIONSHIP TO PATIENT

AUTHORIZATIONS

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Medford Foot & Ankle Clinic, PC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance; and for obtaining any referrals or authorizations if required by my insurance carrier. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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.

DATE

Signed

GENERAL HEALTH INFORMATION

Shoe Size

Weight

Height

Most Current Blood Pressure

Are you allergic or sensitive to:

Medication Allergies:

Tape?

Betadine (Iodine)

Latex?

Any problem with local anesthetics?

Any problems taking aspirin or ibuprofen?

Name of your Pharmacy:

List Current Medications and Supplements/Vitamins:

Smoking:

Never Smoked Former Smoker Current Smoker

Frequency:

If Yes, How Long?

List any serious illnesses

List any major surgeries

If yes, for what condition?

Physician treating this condition?

Last date you saw this doctor?

MEDICAL INFORMATION

This Information is Important For Our Records And Your Health

Describe your foot problem

How long has it been bothering you?

Days

Weeks

Years

List any past problems of your feet and ankles

List any past surgical procedures on your feet or ankles

If yes, where?

FAMILY HISTORY

Please list family member (blood relative) that has a history of:

Please select ALL that apply:

CONSENT

I certify that the above information is true & correct to the best of my knowledge. I give permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/ or treatment of my condition.

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.

Signature

Date

Patient Payment Policy

Your insurance company may pay all, a portion or none of your bill for services provided. Because of this you are asked to assume responsibility for any uncovered balance on your account. Payment guidelines for office charges are as follows:

Insured Patients

We bill all insurance plans, according to the insurance provided by the patient at time of service. It is your responsibility to give us updated insurance information.
Your insurance company requires us to collect co-payments at the time of service. Waiver of copayments may constitute fraud under state and federal law. Please help us in upholding the law by paying your co-payment at each visit. Additionally, you may have coinsurance and/or deductible amounts required by your insurance carrier. Any outstanding balance on your account, after adjusting for all of your insurance’s responsibilities, will be billed to you.
Payment in full is due at the time of service, for patients who do not provide a copy of their insurance card.
Payment plans are not accepted for co-payments.
Medical services that are considered by your insurance company to be non-covered, out of network, or not medically necessary will be your responsibility. Payment plans available for these services upon request.

Uninsured Patients

You will be asked to pay for the services in full at the time of service. A 10 % discount will be given if paid in full at time of service. If you are unable to pay for the services in full, you will need to make a $100 deposit on your account and establish a payment plan with the billing department before your scheduled appointment.

All Patients

Payment is to be paid in full within 30 days of receiving your statement. All billing disputes must be submitted in writing within 30 days of receipt of statement. All patient responsible balances that remain delinquent after 90 days may be referred to a collection agency with a 20% fee added to your balance for collection fees.
Patients who directly receive insurance payments for services provided at our office are asked to send the check with EOB to our Billing Department as soon as possible.
If you are unable to keep your appointment with us, please give us at least 24 hours notice. This courtesy enables us to offer your original time to another patient that needs to be seen. After three occurrences, without 24hours notice there will be a $25.00 charge.
Checks returned to us from the bank for non-payment or insufficient funds, will be charged $25.00.

I have read and understand the above payment policy.

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.

Signature

Date

Authorization to Disclose

Name of Patient;

I understand that if the person (s) or entity (ies) that receives the information is not a health care provider or a health plan covered by federal privacy regulations, the information described below is no longer protected by those regulations.

This authorization may be revoked at any time, and must be in writing, signed by me or on my behalf, and delivered to the address at the bottom of this form. This shall remain in effect from the date of signing until rescinded by patient or on my behalf.

AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION & BILLING INFORMATION REGARDING PATIENT BELOW

This authorization must be written, dated and signed by patient or by a person authorized by law to give the authorization.

I authorize Medford Foot and Ankle Clinic Staff to release specific health information regarding my care and treatment; and to discuss billing and accounting inquiries on my behalf. To the following recipient (s):

Add new row

Print Name:

Date

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.

Signature:

Date:

Witness:

Date:

Your information will be encrypted.