New Patient Paperwork Form

Please correct the errors described below.

Patient

Responsible Party ( If other than patient)

Emergency Contact Information

Federal Government Requirements

Notice of Patient Privacy Practices (HIPAA)

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand my health information can and will be used to (1) conduct, plan and direct my treatment and follow up among multiple healthcare providers who may be involved in that treatment directly and indirectly. (2) Obtain payment form third-party payers. (3) Conduct normal healthcare operations such as quality assessments and physician certifications. I know that I can request a copy of the Notice of Privacy Practices which contains a more complete description of the uses of disclosures of my health information from Cascade Foot Center at anytime. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact Cascade Foot Center at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Cascade Foot Center restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I understand that Cascade Foot Center is not required to agree to my restrictions but if it does agree, then it is bound to abide by such restrictions. I permit Cascade Foot Center to communicate test results, doctor's instructions, and appointment reminders in the above marked manner.

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.

Medical History

Family History

Surgical History

    Please upload a file

    Billing/Account Policy

    (Please read the following carefully and ask questions before signing)

    Patient Financial Responsibility. You are financially responsible for payment of your medical care at Cascade Foot Center. If you are uncertain whether your services or products are covered by your insurance plan, you should confirm this with your insurance carrier prior to your appointment. You are responsible to obtain referral and/or authorizations for your services as may be required by your policy. Our office is not responsible to obtain referral and/or authorizations for your services as may be required by your policy. Our office is not responsible for charges denied because a referral was not obtained before services were rendered. Co-payments are due at the time of your appointment. When we are have complete billing information, we are able to bill most insurance companies directly for you. You are responsible for deductibles, copayments, and services or products not covered by your insurance carrier. If you have a balance owing to us, the balance is due within 45 days of the date of our first statement. If you are unable to pay within 45 days, you must contact our Accounts Department to establish a payment plan to ensure no further action will be taken on your account. Your first two monthly statements will be sent to you free of charge. After that time, each billing statement issued will incur a $4.00 statement fee until your account is paid in full. If you do not have insurance coverage, we currently offer our patients a 10% discount off our regular fee schedule. Payment of your bill is DUE AT TIME OF SERVICE. If you have a high deductible a $100 payment is due at the time of service. There will be a $25.00 fee for any check returned by your bank for non-sufficient funds. I understand there will be a $20.00 "NO SHOW" cancellation fee charged to me if I fail to have a 24 hour notice. If we are required to turn over your account for collections, in addition to your account balance, you agree to pay any and all collections fees whether litigations is commenced or not, including attorney fees. I understand and agree to the terms of Cascade Foot Center Billing Policy.

    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.

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