New Patient Form

We would like to welcome you to our office. Thank you for choosing us for your podiatric services.

First Name

Middle Name

Last Name

Age

Birthdate

Race

Ethnicity

Hispanic Non-Hispanic

Mailing Address

City

State

Zip

Street Address

City

State

Zip

County

Driver License #/State

Sex

M F

Marital Status

Single Married Divorce Widowed

Home Phone

Cell Phone

Preferred Method of Communication

Phone Portal Email

Social Security Number

How did you find out about us

Family/Friend Internet Doctor Phone Other

If other, please indicate

Patient’s Employer

Work #

Occupation

City / State

If disabled, reason for disability

Spouse’s Name

DOB

SS #

Please indicate full 9 digits

Emergency Contact (not at the same phone number)

Phone #

The following are permitted to obtain my medical information

Were you referred for consultation?

By Whom?

Who is your Primary Care Physician?

Pharmacy/Location

INSURANCE INFORMATION

Please provide your insurance card(s) for photo copying. (Without current insurance cards you will be considered a Self-Pay account. No Exceptions.)

Add file

Please upload a file

PLEASE READ CAREFULLY

I give permission to PMFAC to administer treatment and to perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my condition. I request that my insurance company pay benefits directly to PMFAC. I agree that I am responsible for any amount not covered by my insurance. I agree that it is my responsibility to obtain any referral necessary from my insurance company or Primary Care Physician as required to process my insurance claims. I give permission to use my cell number as a contact number regarding my account.

In the event that I need hospitalization, surgery and/or durable medical equipment, I agree that it is my responsibility to inform the Doctor of my insurance company requirements regarding precertification, second opinions and other requirements.

I understand that monthly finance charges will be added to overdue accounts. I understand that even though Purvis-Moyer Foot & Ankle Center files with my insurance company, if for some reason they do not pay, I accept full responsibility for payment.

AUTHORIZATION TO RELEASE/RECEIVE MEDICAL INFORMATION

I authorize Purvis-Moyer Foot & Ankle Center to release and/or receive medical information to or from my insurance company or any facility that requires information to provide payment or outside care.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF 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 understood the Notice.

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.

Patient’s/Responsible Party’s Signature

Date

Relationship

Your information will be encrypted.

New Patient Form

INSURANCE INFORMATION

PLEASE READ CAREFULLY

AUTHORIZATION TO RELEASE/RECEIVE MEDICAL INFORMATION

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

PURVIS-MOYER FOOT & ANKLE CENTER – PMFAC