Redondo Beach Podiatry Group
To Our New Patient:
Welcome to Redondo Beach Podiatry Group! We are thrilled that you have chosen our team for your foot and ankle needs. We will do our best to provide you with the most up-to-date and comprehensive podiatric care available. We have a total commitment to keeping your feet healthy – and keeping you happy.
To maximize your time with us, we ask that you bring the following to your first visit: photo identification, medical insurance card(s), written referral (if required by your insurance company), and prior medical records and x-rays (if applicable).
In addition, please complete and sign the New Patient Forms included with this letter. These include our Patient Registration, Comprehensive Health Review(include all current medications and dosages), and Consent to Treat.
Whether you have a serious foot health condition or you’re just looking for added comfort, Redondo Beach Podiatry Group is here to provide the best podiatric care possible. We look forward to your appointment with us!
Sincerely,
PS – Please visit us online at www.RBPodiatry.com for additional patient information and our Notice of Privacy Policies.
PATIENT INFORMATION
The above information is true to the best of my knowledge. I certify that I have insurance with the insurance company(ies) disclosed and assign directly to RedondoBeach Podiatry Group all insurance benefits, if any, otherwise payable to me for service(s) rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature below on all insurance submissions. Redondo Beach Podiatry Group may use my health care information and may disclose such information to the disclosed insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
(include RX meds, OTC meds, and Vitamins)
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For Office Staff
The information I have provided is true to the best of my knowledge. I recognize that the information I have provided will help me receive the best possible care.
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.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Redondo Beach Podiatry Group Notice of PrivacyPractices and that I have read (or had the opportunity to read if I so chose) and understand the Notice.
AUTHORIZATION REGARDING PRIVACY POLICY
Due to the recent implementation of the Patient Privacy Act (HIPPA), I hereby authorize RedondoBeach Podiatry Group to leave messages at my home with family members and/or answering machines regarding the following: (1) Confirm or Change Appointment, (2) Results of testing ordered by the physician, and/or (3) Any pertinent information that may be relative to my care.
ACKNOWLEDGMENT OF RECEIPT OF FINANCIAL POLICY
I acknowledge that I was provided a copy of the Redondo Beach Podiatry Group Financial Policy and that I have read (or had the opportunity to read if I so chose), understand and will comply by the policies stated.
CONSENT TO VIEW EXTERNAL PRESCRIPTION HISTORY
I authorize Redondo Beach Podiatry Group to view my external prescription history via electronic prescribing services. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, pharmacies and pharmacy benefit managers may be viewable by my provider and staff at Redondo Beach Podiatry Group and it may include prescriptions back in time for several years.
PATIENT CONSENT
I hereby voluntarily consent to outpatient care by a Redondo Beach Podiatry Group Podiatrist, encompassing routine care, diagnostic procedures, examination and medical treatment including, but not limited to, minor surgical procedures, routine laboratory work, x-rays, ultrasound, photographs and administration of medications and injections prescribed by theRedondo Beach Podiatry Group Podiatrist. I agree to ask questions to clarify treatment should I not understand the treatment plan.
INSURANCE ASSIGNMENT AND RELEASE
I certify that I have insurance with the insurance company(ies) disclosed and assign directly toRedondo Beach Podiatry Group and its Podiatrists, all insurance benefits, if any, otherwise payable to me for service(s) rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I agree that should my account become delinquent and is referred to an attorney or collection agency for collection, I will be charged an additional 33 1/3%of any unpaid balance at the time of referral for all costs of collection and attorney's fees. I authorize the use of my signature below on all insurance submissions.
Redondo Beach Podiatry Group may use my health care information and may disclose such information to the disclosed insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
DISCLOSURE OF SERVICES
I understand that Redondo Beach Podiatry Group is owned and operated by Dr. Darragh. During my course of treatment, products may be recommended. I understand that I am under no obligation to purchase these products and that i may find alternate sources to purchase these products.
I have read and fully understand this Consent to Treatment. This authorization is valid as of the date I have signed below and will remain in effect as long as I am a Redondo Beach Podiatry patient. I have read this complete page and agree to all of its contents.
1. All co-payments are due at the time of visit. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered a violation of the contract you have with your insurance company.Our office accepts cash, checks (post‐dated checks are not accepted), credit and debit cards
2. Co-insurance and unmet deductibles are due prior to scheduled surgeries and procedures.Once benefits are verified and your financial responsibility calculated, you will be notified of the payment amount and due date.
3. You are ultimately responsible for payment of charges for services you receive from our office
4. In accordance with your insurance member handbook, it is your responsibility to provide accurate insurance information and to present your insurance ID card at the time of your visit.If you do not have insurance or do not present a valid insurance card, you will be responsible for payment at the time of service.
5. It is your responsibility to ensure that our physicians are in your insurance network.
6. If your plan requires a referral, it is your responsibility to obtain this prior to being seen by our provider.
7. Payment is due for rendered services 10 days from receipt of your billing statement.Outstanding balances must be paid in full prior to any additional visit unless arrangement shave been made with our billing department
8. There is a service fee of $35 for each time a check is returned. The bank may return your checkup to three times before considering it nonnegotiable. Your insurance company does not cover this fee
9. A scheduled appointment means that time has been reserved for you. Cancellations for appointments must be received at least 24 hours prior to the scheduled appointment. Cancellations for scheduled surgery and in‐office procedures must be received at least 5days prior to the scheduled surgery date and time.
10. Patients who fail to keep or fail to cancel a scheduled appointment may be charged a $25.00No Show Fee. There is a $100.00 cancellation fee for scheduled surgeries or in‐office procedures that are cancelled less than 5 business days from the date and time of surgery unless cancellation is due to insurance denial or medical necessity.
12. Administrative Services: There is a $25.00 charge for each required Administrative Service, payable prior to service completion. This Administrative Service Fee covers specific administrative services such as forms completion for family medical leave and disability, letters for insurance authorizations for brand or non-formulary drugs, letters for employers, school, health clubs, and any other administrative items not covered by insurance
13. In the event your insurance company should happen to send payment to you(the patient), you agree to forward said payment to our office to be applied to your account.
14. SELF-PAY: Payment in full is due at the time of service if you do not have health insurance coverage.
Written Acknowledgment Form
Our Notice of Privacy Practices (NPP) provides information about how we may use and disclose medical information about you.
I, (Please input Name below), with the date of birth (Please input date below) have been provided access to a copy of the Redondo Beach Podiatry Group's NPP for review.
I hereby consent to the release of any/all information regarding my medical history, current medical condition, current medical treatment and any/all patient account information to the individual(s) listed below: (If you would not like any information to be released, please leave blank).
** Notice of Privacy Practices * *
Phillip E. Darragh, DPM & Robert Anavian, DPM
This Notice describes how Medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
The privacy of your medical information is important to us.
Our Legal Duty
We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect January 1, 2020, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided that such changes are permitted by applicable law. We reserve the right to make changes in our privacy practice sand the new terms of our notice effective for all protected health information that we maintain, including medical information we created or received before we made the changes.
You may request a copy of our notice (or any subsequent revised notice) at any time. For more information about our privacy practices, or for additional copies of this notice, please contact our office.
Uses and Disclosures of Protected Health Information
We will use and disclose your protected health information about you for treatment, payment, and healthcare operations.
Following are examples of the types of uses and disclosures of your protected health care information that may occur. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health care and related services. This includes the coordination of management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will disclose protected heath information to other physicians who may be treating you. Your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
In addition, we may disclose your protected health information from time to time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for protected health necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
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