New Patient Form

Name:

Chart #:

Date of Birth:

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Declined to Specify

Race:

Asian

White

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Black or African American

Declined to specify

Preferred Language:

Decline to specify

Pharmacy Name:

Pharmacy Phone:

Pharmacy Address:

City:

State:

Zip:

Primary Care Physician:

Phone:

Date Last Seen:

Referring Physician:

Phone:

Date Last Seen:

Privacy Information Preferences

Do you want to be exempt from public reporting?

Yes No

Can we send mail to the address on file?

Yes No

Can we call the phone number on file?

Yes No

Can we leave voicemail on machine?

Yes No

Will you allow us to send internet based (e-mail) delivery of reminders and newsletters?

Yes No

If yes, please provide your e-mail address:

Who can we leave messages with?

Wife

Husband

Daughter

Son

Other

If other, Name(s)

Smoking Status

Current Every Day

Smoker, Current Status Unknown

Current Some Day

Heavy Tobacco

Unknown If Ever

Former

Never

Light Tobacco

l decline to answer

Vital Signs

Blood Pressure:

Height:

Weight:

Current Medications

No Known Medications I take the following Medications:

Add Medication

Allergies

No Known Medications No Known Drug Allergies

Add Allergies

Did you get a pneumoccal vaccination?

Yes No

Have you fallen in the last 12 months?

Yes No

Were you injured from the fall?

Yes No

Advanced Directives:

Living Will DNR Durable Power of Attorney Surrogate Appointed None

PLEASE READ AND SIGN: The information on my intake form(s) is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. (Assignment of Benefits): I authorize payment of medical benefits to the practice named above. (Release of Information): I authorize the release of any medical information necessary to process this claim. (HIPAA Privacy): I acknowledge that I received my HIPAA Privacy Practices Notice. (Medication History): I authorize the Doctor's office to retrieve my medication history.

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 Signature:

Date:

History and Physical

Medical History:

If Neuropathy, specify:

If Arthritis, specify:

If Thyroid disease, specify:

If Other, specify:

Are you Pregnant?

Yes No

Are you Nursing?

Yes No

Surgical History

None

Appendectomy

C-Section

Angioplasty

Bypass

Cataracts

Cholecystectomy

Have you ever had any surgical procedures on foot/ankle or anywhere else on your body?

Yes No

If yes, please describe:

Do you have any artificial joints?

Yes No

If yes, where?

Do you have an artificial heart valve?

Yes No

Social History

Do you smoke?

Yes No

If yes, how many packs per day?

For how long?

Do you drink alcohol?

Yes, everyday (5-7 days/week) Yes, occasionally/socially No/Rarely

If yes, I have a current substance abuse problem, Please specify:

If yes, I had a past substance abuse problem, Please specify:

What is your Occupation?

Does it involve mostly

Standing Sitting

Do you exercise regularly?

No, I do not exercise regularly Yes, I do the following regular exercise:

If yes, Specify:

Family History

Is there any family history (blood relative) of: (Please indicate family member)

Alzheimer's

Arthritis

Bleeding disorders

Blood clot

Cancer

Cataracts

Circulation Problems

Depression

Diabetes

Emphysema

Heart disease

High Blood Pressure

Neurological

Strokes

Review of Systems

(Please check the box if you currently have any of these symptoms or check "NONE")

Genitourinary

Blood in urine

Decreased Frequency

Hesitancy

Excessive Urination

Incontinence

Kidney disease

Increased Urgency

Kidney Stones

NONE

Integumentary

Athletes Foot

Nail Abnormalities

Keloids

Itchiness

Dry, Scaly skin

NONE

Hematologic

Lower Leg Ulcers

Sickle Cell Disease

Anemia

Blood Thinners

Clotting Disorders

NONE

Neurological

Tingling

Tremors

Weakness

Paralysis

Seizures

Numbness

Headaches

NONE

Respiratory

Chest Pain

Shortness of Breath

Wheezing

Emphysema

COPD

Coughing

Snoring

NONE

PLEASE READ AND SIGN

The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above.

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 Signature:

Date:

Name:

DOB:

Chart Number:

Sex:

M F

Marital Status:

Single Married Widowed Divorced

SS #:

Email address

Spouse/Partner Name:

Address:

City:

State:

Zip:

Home #:

Cell #:

Other #:

Employer:

Phone:

Employer Address:

City:

State:

Zip:

Primary Insurance:

Are you Insured?

Yes No

Insured Information

Subscriber Name:

Relationship to Insured:

Spouse Child Self Other

Phone #

Sex:

Male Female

DOB:

Address:

Policy ID:

Group ID:

Employer:

Secondary Insurance:

Are you Insured?

Yes No

Insured Information

Subscriber Name:

Relationship to Insured:

Spouse Child Self Other

Phone #

Sex:

Male Female

DOB:

Address:

Policy ID:

Group ID:

Employer:

How did you find out about our Practice?

Physician

Internet

Telephone Book

Family member

Friend

Other

If other, specify:

What is the reason for your visit today?

Result of Accident or Work injury?

Yes No

How long this bothered you?

1 2 3 4 5 6 7

Days Weeks Months Years

What treatments have you tried and have they been effective?

On a scale of 1-10 (1 being no pain and 10 being the worst) what is your level of pain?

The pain quality is:

Burning

Constants

Dull

Sharp

Shooting

Throbbing

Tingling

Other:

If other, specify:

PLEASE READ AND SIGN

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 Signature:

Date:

PATIENT FINANCIAL POLICY

Edward C. Kormylo, DPM, FACFAS | Kristina Karlic, DPM, FACFAS | Sara El Bashir, DPM, FACFAS |
Joseph Zehentner, DPM, AACFAS | Sandra Zawadka, DPM, AACFAS

285 Sills Road, Building 17, East Patchogue, NY 11772

976 Roanoke Avenue, Riverhead, NY 11901

1641 Route 112, Suite A, Medford, NY 11763

283 Commack Road, Suite 125,Coomack, NY 11725

2112 Middle Country Rd, Centereach, NY 11720

Phone: (631) 654-5566

Phone: (631) 381-0201

Phone: (631) 447-0800

Phone: (631) 499-3505

Phone: (631) 993-8100

Fax: (631) 654-8250

Fax: (631) 381-0203

Fax: (631) 447-0801

Fax: (631) 499-5421

Fax: (631) 654-8250

Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff.

As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office.
Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable time, we will have to look to you for payment.
We have made prior arrangements with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the copay/coinsurance/deductible at the time of service.
If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payments directly to you.Therefore, all charges for your care and treatment are due at the time of service.
All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be not covered, or you do not have an authorization, you will be responsible for the complete charge.
You must inform the office of all insurance charges and authorization/referral requirements. In the event the office is not informed, you will be responsible for the charges denied.
For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.
There are certain elective surgical procedures for which we require prepayment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.
Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due at this office.
There is a service fee for $35.00 for all returned checks. This is not covered by your insurance company.

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.

Signature of Patient/Responsible Party:

Date:

Printed Name of Patient/Responsible Party:

Date:

Email Address:

Witness:

Your information will be encrypted.