New Patient Forms

Patient Information

Patient Last Name:

Patient First Name:

Patient MI:

Date of Birth:

Home Address:

City:

State:

Zip Code:

Apt. #:

Home Ph #:

Social Security Number:

Day Ph #:

Spouse Name:

Phone:

Email address

Responsible Party if Patient a Minor:

Primary Insurance Company:

Policy Number:

Group #:

Claims Address:

Phone Number:

Co-pay:

Policy Holder:

Secondary Insurance:

ID #

Claims Address:

Phone Number:

Policy Holder:

Whom may we thank for referring you to this office?

Medical History

Family Physician:

Has he/she requested you to be seen in our office?

Yes No

Former Podiatrist:

What problems bring you to our office?

Add Medications

Please check “Yes” or “No” to indicate whether you have had any of the following problems.

Recent weight loss

Yes No

Approximate Date

Comments

Headaches

Yes No

Approximate Date

Comments

Trouble with vision

Yes No

Approximate Date

Comments

Trouble with hearing

Yes No

Approximate Date

Comments

Allergies/Hay Fever

Yes No

Approximate Date

Comments

Asthma

Yes No

Approximate Date

Comments

Allergic reaction to Medication/Latex

Yes No

Approximate Date

Comments

Thyroid

Yes No

Approximate Date

Comments

Diabetes

Yes No

Approximate Date

Comments

Skin Problems

Yes No

Approximate Date

Comments

Anemia

Yes No

Approximate Date

Comments

Heart

Yes No

Approximate Date

Comments

Mitral Valve Prolapse/Heart Murmur

Yes No

Approximate Date

Comments

Circulation

Yes No

Approximate Date

Comments

High Blood Pressure

Yes No

Approximate Date

Comments

Chest Pain

Yes No

Approximate Date

Comments

Lungs (COPD, Pneumonia, TB, etc.)

Yes No

Approximate Date

Comments

Shortness of Breath

Yes No

Approximate Date

Comments

Cough, pleurisy, wheezing

Yes No

Approximate Date

Comments

Liver or Gall Bladder Disease or Jaundice

Yes No

Approximate Date

Comments

Stomach Trouble

Yes No

Approximate Date

Comments

Swelling in Feet or Ankles

Yes No

Approximate Date

Comments

Arthritis

Yes No

Approximate Date

Comments

Kidney Disease or Stones

Yes No

Approximate Date

Comments

Gout

Yes No

Approximate Date

Comments

Bleeding Tendency

Yes No

Approximate Date

Comments

Scarring Tendency

Yes No

Approximate Date

Comments

Joint Pain or Stiffness

Yes No

Approximate Date

Comments

Numbness in Feet or Legs

Yes No

Approximate Date

Comments

Cramps in Feet or Legs

Yes No

Approximate Date

Comments

Lower Back Pain

Yes No

Approximate Date

Comments

Do you Smoke

Yes No

How Much

Comments

Do you drink

Yes No

How Much

Comments

Do you take any drugs

Yes No

How Much

Comments

Fainting & Convulsions

Yes No

Approximate Date

Comments

Stroke

Yes No

Approximate Date

Comments

HIV Positive

Yes No

Approximate Date

Comments

Psychiatric

Yes No

Approximate Date

Comments

Pain in other areas

Yes No

Approximate Date

Comments

RELEASE & ASSIGNMENT OF BENEFITS

I hereby authorize payment of medical and surgical benefits directly to Fred O. Kussel, D.P.M., and to release any information, including the diagnosis and treatment rendered to me.
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration, its intermediaries or carriers any information needed for this or related Medicare claim.
I request that payment of authorized benefits payable for physician services be paid directly to Fred O. Kussel, D.P.M. for services rendered to me. I also understand that Dr. Kussel will accept assignment of all Medicare covered services provided that I pay the 20% of the approved amount and have met my deductible.
I understand that I am ultimately responsible for any charges regardless of my insurance. Dr. Fred Kussel’s office will make all reasonable attempts to obtain payment from my insurance company. However, if these attempts fail, I realize that I am responsible for the charges, including the 20% co-pay for Medicare or any HMO or PPO co-pays. These fees are due when services are rendered.
I understand that original x-rays are property of the practice and I can request copies for a fee and must allow adequate time to obtain these copies.
I understand that I am responsible for the payment of Custom Fitted Orthotics and that this payment is non-refundable due to the nature of the device being made specifically to my feet.

Signature:

Date

PRIVACY HEALTH INFORMATION- PRACTICE’S REQUIREMENTS

The Practice:

(a) Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI.
(b) Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided under federal law.
(c) Is required to abide by the terms of this Privacy Notice.
(d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
(e) Will distribute any revised Privacy Notice to you prior to implementation.

Will not retaliate against you for filing a complaint.

EFFECTIVE DATE

This notice is in effect as of 04/15/2003.

PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

Patient:

Date

Due to HIIPA guidelines, we can not give out any medical information unless we have your written consent to do so. It is important for us to know who you would like us to give information to in case we receive a call. If you are a single parent it is most important to know if we can speak to the other parent of the minor child.

Please give us a list of the persons we may speak to regarding your account. If this information changes it is important for you to call our office immediately to update this list.

Add new row

Please give us a specific list of names that you DO NOT want any information released to:

Add new row

Please list specific medical conditions that you do not want us to discuss with anyone.

Add new row

Signature

Date

SUMMARY OF THE FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES

Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows:

A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.

A patient has the right to a prompt and reasonable response to questions and requests.

A patient has the right to know who is providing medical services and who is responsible for his or her careA patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.

A patient has the right to know what rules and regulations apply to his or her conduct.

A patient has the right to be given by the health care provider information concerning diagnosis. planned course of treatment, alternatives, risks, and prognosis.

A patient has the right to refuse any treatment, except as otherwise provided by law.

A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care

A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.

A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care

A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained

A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment.

A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.

A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.

A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.

A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations. medications, and other matters relating to his or her health.

A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.

A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.

A patient is responsible for following the treatment plan recommended by the health care provider.

A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.

A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions.

A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.

A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.

CHART UPDATE

Please answer all of the following questions so that we may update your chart. This information required for the current Government regulations for tracking purposes only.

Circle the appropriate choice

1.) Gender

a. Unknown b. Male c. Female d. Other

2.) Race:

a. Unknown b. American Indian/Alaska Native c. Asian d. Black/African American e. Native Hawaiian/ Pacific Islander f. White

3.) Ethnicity:

a. Unknown b. Hispanic or Latino c. Non Hispanic Latino

4.) Language:

a. Unknown b. English c. Spanish d. French e. Russian f. Itaian g. Dutch

5.)

a. Current, every day b. Current, some days c. Former d. Never e. Former, current unknown f. Unknown

6.) E-mail Address:

7.) Pharmacy Name:

8.) Pharmacy Location:

8.) Pharmacy phone number:

Patient Signature

Date

Office Policy On Billing

The following bullet points are very important for you to read and understand regarding our billing policy.

Before your initial appointment this office will check your insurance coverage and what responsibility you will have. It is important for you to understand that when we do this the insurance company makes it very clear to us that what they tell us is not a guarantee of payment and that it is subject to change when the claim is processed. Therefore, when we inform you of your benefits they are not written in stone and are subject to change at your insurances companies discretion. It would also be advisable for you to also call your insurance company and verify your coverage as well as to whether or not Dr. Kussel is participating with your particular insurance.
This office will charge an additional fee for any Medical Records and copies of X-Rays that you may request. There will be no exceptions. A 48 hour notice is required.
Please understand that your insurance is a contract between you and them. We have no control as to what they put to your responsibility. However, due to our contract with the insurance companies we are not at liberty to adjust off balances for co-pays, deductibles and co- insurance rates.
This office collects all financial obligations that we are aware of on your account before you are seen by the doctor.
If for some reason the insurance does put an obligation to you that we were not aware of, we will mail out a bill to you. It is very important that you make payment on that billing within 30 days. Effective January 1, 2009 we have implemented a service fee of $1.00 for every bill we have to mail after that.
Please provide your insurance cards and a photo ID at your initial appointment that we can copy for your chart. It is your responsibility to inform us if your insurance changes. It is not the responsibility of this office to check your insurance for every appointment.

Patient Signature

Date

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