Ribeiro Foot & Ankle Center

Patient Registration Form

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PATIENT INFORMATION

FINANCIALLY RESPONSIBLE PARTY (if different from patient)

INSURANCE INFORMATION (copy of card(s) required)

HOW DID YOU HEAR ABOUT US?

FAMILY PHYSICIAN INFORMATION

MEDICAL HISTORY

ALLERGIES

REVIEW OF SYSTEMS

LIST OF CURRENT MEDICATIONS

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WHAT PREVIOUS SURGERIES HAVE YOU HAD?

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BLOOD RELATIVE

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BLOOD RELATIVE

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I understand the above medical information is necessary to provide me with medical care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to as the respective health care provider or agency, which may release such information to you. I will notify the doctor of any changes in my health or medication.

I HEREBY GIVE AUTHORIZATION FOR TREATMENT

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Financial Policy

We are dedicated to providing the best possible care and service to you and regard your completed understanding of our financial policies as an essential element of your care and treatment. I authorize payment of medical benefits to Dr. Carla Ribeiro-Bachtell for all services provided. As our patient, you are responsible for making sure that the bill is paid in full. All charges are your responsibility and not the insurance company's. We must emphasize, as your podiatric medical care provider, that our relationship is with you and not your insurance company. Your insurance is a contract between you and the insurance company, As a courtesy, we will file your insurance claim for you. The filing of a medical insurance claim is an expensive process and a courtesy that we extend at no charge. However, we do ask that you pay all co-pay, deductible and non-covered charges on the day of your service. If you insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. Self-pay patient are required to pay in full at time of service unless prior arrangements have been made. If a service is not covered, applied to your deductible or part of your coinsurance, you will have (30) days to pay the balance in full. If you fail to pay in a timely manner, you understand that your account will be subject to collection proceedings. All fees, including collection fees, attorney fees and other court fees shall become your responsibility in addition to the balance due at this office. If payment is not received in the (30) days required and additional statement must be sent to collect the balance, a $10.00 re-billing fee will be added to each statement until the balance is paid in full. I understand that it is my responsibility to provide the office with my current insurance card at the time services are rendered to me. If I cannot provide my current insurance card, my appointment will be rescheduled or I will choose to pay for services out of my pocket. I understand that if I provide incorrect or expired information, I will assume full financial responsibility for all charges incurred. I understand that my account may be charged a $30.00 cancellation fee if I do not call to cancel my appointment at least (24) hours before my scheduled appointment time. There is a $60.00 cancellation fee for office procedures such as biopsies, nail procedures, wart removals, etc. The amount must be paid prior to any further visits with our office. I understand that my account may be charged a $150.00 cancellation fee if I do not call to cancel my surgery at least (72) hours in advance before my scheduled surgery time. This amount must be paid prior to any future visits to our office. For your convenience, our office accepts all major credit cards, checks, and cash. You agree to be responsible for a $25.00 service fee for all returned checks. The courts have established the x-rays are the property of the doctor who takes them as part of the patient's medical record. The office is able to burn a copy of the x-rays onto a CD. There is a $5.00 fee for this service. Medicare requires a minimum of 60 days between visits for at-risk patients for routine foot and nail care. Please note that Medicare may not qualify for routine trimming of nails and/or calluses. Any charges outside of Medicare guidelines will be the responsibility of the patient. By signing this document, I acknowledge that I have read it, understand and agree to the above-stated terms and conditions.

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

SUMMARY OF NOTICE OF PRIVACY PRACTICES

This summary is provided to assist you in understanding the Notice of Privacy Practices

The Notice of Privacy Practices contains a detailed description of how our office will protect your health information., your rights as a patient and our common practice in dealing with patient health information.

Uses and Disclosures of Health Information

We will use and disclose you health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by is or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students.

Uses and Disclosures Based on Your Authorization

Except as stated in more detail in the Notice of Privacy Practices, we will no use or disclose your health information without your written authorization.

Uses and Disclosures Note Requiring Your Authorization

In the following circumstances, we may disclose your health information without your written authorization: - To family members or close friends who are involved in your health care; - For certain limited research purposes; - For purposes of public health and safety; - To Government agencies for purposes of their audits, investigations and other oversight activities; - To government authorities to prevent child abuse or domestic violence; - To the FDA to report product defects or incidents; - To law enforcement authorities to protect public safety or to assist - in apprehending criminal offenders; - When required by court orders, search warrants, subpoenas and as otherwise required by law.

Patient Rights

As our patient, you have the following rights: - To have access to and/or a copy of your health information; - To receive an accounting of certain disclosures we have made of your health information; - To request restrictions as to how your health information is used or disclosed; - To request that we communicate with your confidence; - To request that we amend your health information; - To receive notice of our privacy practices. If you have a question, concern or complaint regarding our privacy practices, please refer to the Notice of Privacy Practices for the person or person whom you may contact.

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 above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

FORM FEES

Due to the amount of time required to fill out administrative paperwork we now have the following policies in place: There is a $20.00 charge, per request for completed of forms you may need. Please allow 5 to 7 business days to complete forms. This includes such forms as a disability form, workers compensation form, FMLA form, leave of absence form, life insurance form, school form, employer forms, MetroAccess forms, handicap parking forms, etc. This must be PRE-PAID when you bring the form to the office or mail in the form. To make payment easy for you, we accept cash, checks, money orders, MasterCard and VISA. There is a $25.00 fee for all returned checks. In some cases you will be asked to complete a 'Release of Medical Records' form before your information can be released. There is a $30.00 charge for expedited completion of forms needed within 2 business days. We will do our very best to try to complete these forms during this time-frame, and will let you know if this is not possible due to doctor's availability. There is a charge for production of any letters needed on office stationary which requires more to produce. It will be billed based on the time it take to generate the letter at a rate of $35.00 per 5 minute increments. The fee will be waived for simple forms requiring just a signature or simple work/school release forms. It is YOUR responsibility to clarify your WORK STATUS with your treating physician during office visits. Bring or mail forms to (along with prepayment check): Ribeiro Foot and Ankle Center 4660 Kenmore Avenue, Suite 602 Alexandria, VA 22304 You will be contacted once your form is available for pickup.

By typing your name above, 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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