NEW PATIENT FORM

Insurance Information

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.

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.

Medications (Including Vitamins and Dosages)

Medication Allergies/Reactions

Personal Social History

Previous Surgeries or Hospitalizations

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.

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

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

• 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.

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.

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.

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.

Patient Prior Authorization Based Upon Insurance Company
Patient Responsibility Consent Form

Dear Patient, It is important that you understand how your medical insurance works and what your responsibility is regarding your medical insurance and seeing a Specialist Provider. If your insurance requires a prior authorization to see a specialist your internal medicine/primary care provider is responsible for initiating a prior authorization for you to be seen. If at the time of your visit an authorization has not been obtained you will be seen as a self-paid patient because your medical insurance company will not cover your visit. Payment in full will be due at the time of check-in to be seen. A prior authorization cannot be back dated after the visit, so it is extremely important that you as the policy holder understand how your plan works and what is required by your plan when seeing a Medical Specialist and for the Specialist to be paid.

it is my responsibility to have all necessary authorization required by my insurance company at the time of my visit with Dr. Dany Y. Jabbour and Rhinebeck Podiatry Services. I further understand that if at the time of my visit I do not have my authorization required by my insurance company that I become a self-paid patient if I want to be seen and agree to pay any all fees at the time of check in, so I may be seen. I am aware that if I do not pay and cancel the appointment with less than 24 hours’ notice I will incur a $50.00 cancellation charge. If I refuse to pay I am aware of the risk of my account being sent to a collection agency who charges a 30% fee of the total charges incurred by Rhinebeck Podiatry Services which will also become my Financial Responsibility.

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.