NEW PATIENT FORM

Patient Information

Last name:

First name:

Middel Initial:

Gender:

Male Female

Date of Birth

Age:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

SSN:

Preferred Language:

English Spanish

Ethnicity:

Hispanic/Latino Non Hispanic/Latino Native Hawaiian/Other Pacific Island

Race:

White Black or African American Hispanic Asian American Indian or Alaska Native Native Hawaiian/Other Pacific Island

Communication Preference:

Email Postal Telephone

Referred by:

Patient Doctor Insurance

Ref. Doctor Name or Patient Name:

Email Address:

Marital Status:

Single Partnered Married Separated Divorced Widowed

Occupation:

Employer:

Emergency Contact:

Phone:

Primary Care Physician:

Phone:

Date of last visit to Physician:

Preferred Pharmacy:

Sports/Activities:

Insurance Information

Is this Patient under 18 years of Age?

Yes No

If yes, please complete the Person responsible for bill section:

Person responsible for bill:

Date of Birth:

Home phone no.:

Address (If different):

City:

State:

Zip:

Is this person a patient here?

Yes No

If yes, indicate patients name:

Primary Insurance Carrier Name:

Subscriber’s name:

Subscriber’s S.S. #:

Birth date

Group No.:

Policy no.:

Co-payment:

If other, Please specify:

Secondary Insurance Carrier Name:

Subscriber’s name:

Subscriber’s S.S. #:

Birth date

Group No.:

Policy no.:

Co-payment:

If other, Please specify:

Concerning Insurance

Patients who are a member of a plan with which we participate are responsible at the time of service for all co-pays, deductibles and non-covered services and materials. Patients who are members of a plan which this office does not participate are fully responsible for all procedures and materials at the time of service. Medicare patients are responsible for non-covered materials, charges applied to their deductible and 20% of the office fees once the deductible has been satisfied. Secondary insurances will be billed if provided.

I have read the above and fully understand my financial responsibilities for all services and materials received in this office.

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.

Signature:

Printed Name:

Date:

Please describe your foot problem:

Have you had any previous foot care or surgery?

Yes No

If yes, by whom:

Current Age

Height

Weight

Shoe Size

If other, please specify:

Female Patients, are you Pregnant:

Yes No

Yes No If “Yes” Due Date:

Authorizing and Release

I consent and authorize release of my protected health information as required, and outlined in the Notice of Privacy Practices (HIPAA). I have read a copy of the Notice of Privacy Practices (HIPAA), and if requested, will be given a copy of such notice.
I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits for services rendered to me, or my child.
I request that payment of authorized Medicare benefits be made on my behalf to Rhinebeck Podiatry Services for services furnished to me by the provider.
I authorize any holder of medical information about me to release it as necessary to the Centers for Medicare and Medicaid Services, its agents, and private insurances to determine these benefits or the benefits payable for related services.
I certify that the above information is correct and I consent to diagnostic procedures including but not limited to X-ray, medical care, and treatment as deemed necessary by Rhinebeck Podiatry Services.
I authorize Rhinebeck Podiatry Services to take medical photographs for charting and educational purposes.

I understand that I am financially responsible for any balance not covered by my insurance.

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 Signature:

Date:

Parent/Guardian:

Date:

Medications (Including Vitamins and Dosages)

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Medication Allergies/Reactions

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Personal Social History

Alcohol:

Yes No

If “Yes” Amount Per Week:

Caffeine:

Yes No

If “Yes” Cups per day:

Tobacco:

Never a Smoker Former Smoker

Years quit:

Type of Smoker:

Current every day smoker Current occasional smoker

Packs per day:

How many years:

Activities:

Exercise:

Previous Surgeries or Hospitalizations

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Reviewed and final completion by:

Date

MEDICAL SUPPLIES

I acknowledge that this office distributes miscellaneous medical "over-the-counter" type supplies and physician dispensed medications that are not covered by insurances but are available for purchase on a cash pay basis. I further acknowledge that this office will not bill the private insurance companies for these purchased items.

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.

Signature:

Date

Patient's Name:

Date of Birth:

Other Name:

Address:

City

State:

Zip:

Social Security #:

I authorize Rhinebeck Podiatry Services to RELEASE my protected health information (PHI) to:

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I authorize Rhinebeck Podiatry Services to RECEIVE my protected health information (PHI) from:

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I release the entities listed above their agents and employees from any liability in connection with the use or disclose of the protected health information..
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the receipt and no longer protected by the Privacy Rule.
I have a right to inspect the health information to be released and may refuse to sign this authorization.
THE INFORMATION AUTHORIZED FOR THE USE OF DISCLOSURE MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT NOT LIMITED TO, DISEASES SUCH AS HEPATITIS, SYPHILLIS, GONORRHEA OR THE HUMAN IMMUNODEFICIENCY VIRUS, ALSO KNOWN AS IMMUNE DEFICIENCY SYNDROME (AIDS).

With this knowledge, I give my authorization to the release of all information in my medical records, including any information concerning my identity, and release RHINEBECK PODIATRY SERVICES, affiliates, agents and employees from any liability in connection with the release of the information contained therein.

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.

Signature:

Date

I authorize Rhinebeck Podiatry Services to VERBALLY discuss the following medical and billing information about me (check all that apply):

Scheduling/appointment information

Medical information including my symptoms, diagnosis, medications and treatment plans

Lab/test results

Billing and payment information

Other:

Rhinebeck Podiatry Services has my permission to discuss the above information with:

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I hereby authorize Rhinebeck Podiatry Services for any provider having treated me or my dependent, to release to government agencies, insurance carriers, or others who are financially liable for such professional and medical care, all information needed to substantiate claim and payment.

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.

Signed:

Date

Your information will be encrypted.