New Patient Paperwork

Salem Foot and Ankle Specialists

Please correct the errors described below.

PODIATRIC REGISTRATION AND HISTORY

1. Patient Information

2. Insurance

INSURANCE ASSIGNMENT AND RELEASE

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named 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. This consent will end when my current treatment plan is completed or one year from the date signed below.

MEDICARE / MEDIGAP AUTHORIZATION

for any services furnished to me by that provider. Doctor or Clinic To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits for related services.

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.

3. Phone Numbers

IN CASE OF EMERGENCY, CONTACT

4. Podiatric History

5. Medical History

Click on "Yes" or "No" to indicate if you have had any of the following:

6. Medications

7. Allergies

Treatment Consent

I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to administer and perform such procedures upon me as the doctor deems necessary,

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 FOR SALEM FOOT AND ANKLE SPECIALISTS

Office visit co-payments are due at the time of service (we are considered a specialist)

For private pay patients, payment is due in full at time of service unless prior arrangements have been made.

We do not require a referral, but your insurance might. Office staff will be happy to assist you in referral/pre-certification procedures, but final responsibility lies with patient to comply with their specific insurance's requirements.

There is a $25 charge for all returned checks.

If you need to reschedule your appointment, please do so within a minimum of 24 hours. If you miss a scheduled appointment without notifying our office a $25 fee will be added to your account. *Note: We do understand not all situations can be controlled. Please try to be courteous and let us know as soon as you can.

If your account must be forwarded to a collection service and/or attorney because of non-payment you will be responsible for all collection fees associated.

Assignment of Benefits

and assign directly to Dr. Salem, Dr. Claytor or Dr. Wimbish of Salem foot and ankle Specialists all insurance benefits payable to me for services rendered. I understand that I am responsible for payment of deductibles, copayments, and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize RELEASE OF MEDICAL INFORMATION to my insurance carrier or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions.

By my signature I acknowledge receipt of a copy of this policy and hereby agree to it's terms.

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.

NOTICE OF PRIVACY PRACTICES

This Notice describes how Health information about you may be used and disclosed and how you get access to this information.

The privacy of your health information is important to us.

Our Legal Duty

We are required by applicable Federal and State law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This notice takes effect 09/.14/2005 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 such changes are permitted by applicable law. We reserve the right to make the changes in our privacy policies and the new terms of our Notice effective for all health information that we maintain. Including health information we created or received before we make the changes. Before we make a significant change in our privacy practices we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practice or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

Uses and Disclosures of Health Information

We use and disclose health information about your treatment, payment and healthcare operations, For example:

TREATMENT: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

PAYMENT: We may use and disclose your health information to obtain payment for services we provide to you.

HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization we can not use or disclose your health information for any reason except those described in this Notice.

TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

PERSONS INVOLVED IN CARE: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, your location, your general condition or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement to your healthcare. We will also use our professional judgment and our experience with common practice to make the best healthcare decisions.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Salem Foot and Ankle Specialists
1934 Braeburn Drive
Salem, VA 24153

I have seen the Notice of Privacy Practices and have been provided an opportunity to review it.

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.

Your information will be encrypted.

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