1500 E. Woolford Rd. Ste. #101 Show Low, AZ [Phone] (928) [Fax] (928) OFFICE POLICIES

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1 1500 E. Woolford Rd. Ste. #101 Show Low, AZ [Phone] (928) [Fax] (928) OFFICE POLICIES PATIENT NAME: DOB: 1. WE REQUIRE PRE-REGISTRATION! ALL APPOINTMENTS WILL BE RE-SCHEDULED IF REGISTRATION FORMS ARE NOT TURNED IN AT LEAST 24 HOURS PRIOR TO YOUR APPOINTMENT. 2. We understand that emergencies and illnesses occur but our office requires at least 24 hours advanced notice be given prior to rescheduling or cancellation of your appointment. If this does not occur, a $25 cancellation fee will be charged. If unpaid for more than 30 days, this charge may be turned over to our Collection Agency and an additional fee may be assessed. This may be waived on a per case basis. 3. Please be aware that we are not in a position to obtain authorizations for your appointments and/or follow-up visits. We recommend that you contact your PCP doctor s office a few days prior to your appointment to confirm your authorization has been obtained. Should you choose to keep your appointment without prior authorization, you will be personally responsible for the cost of this visit. There can be no exceptions to this policy. Keep in mind this does not apply to all patients, only patients with insurances requiring referrals and authorizations. 4. In order for you to be seen by the doctor you must complete and sign all patient information forms. 5. Written consent from a legal parent or guardian is required for all patients who are minors. 6. Unfortunately, if you miss three appointments, we will be forced to terminate you from our practice so please make every effort to keep your scheduled appointments. 7. We request 48 hours for medication refill requests so please plan accordingly when your medication is running low. Routine medication refill requests will only be addressed during normal business hours. 8. We request 48 hours for the opportunity to process your requested paperwork if it is given to our office outside of your appointment time. We also reserve the right to charge you (not your insurance) for this service. 9. Charges for medical services are due and payable at the time services are rendered, unless other arrangements have been made in advance with my office staff. 10. If unusual circumstances make it impossible for you to meet your payment terms, I invite you to call or personally discuss the matter with my billing manager. This will avoid misunderstanding and enable you to keep your account in good standing. 11. There will be a $25.00 charge on all returned checks. 12. Accounts (90) ninety days past due will be turned over to our collection agency and an additional 65% will be added to your account. 13. If this office is contracted with your insurance then you are fully responsible for any co-pays or deductibles at the time of service. 14. If this office is not contracted with your insurance, it should be understood that your policy is a contract between you and your insurance company. It is important that you understand its provisions. We cannot guarantee payments of your claims. You are responsible for the full payment of your bill regardless of the status of your insurance claim. If your insurance company pays only a portion of the bill or rejects your claim entirely, an explanation should be mailed to you, the policyholder. Reductions or a rejection of your claim by your insurance company does not relieve you of your financial obligation to us. 15. As a patient, it is your responsibility to present all of your insurance information to this office. Failure to notify this office of any changes in your insurance, will result in you being financially responsible for all charges. 16. This office will take reasonable steps to protect patients, visitors, and employees from unauthorized photography, video or audio recordings, or other images. If recording is necessary it will be done by office equipment. Personal cell phones or other devices may not be used. THIS FORM SHALL REMAIN IN EFFECT UNTIL REVOKED IN WRITING. I HAVE READ AND UNDERSTAND THE POLICIES OF THIS OFFICE AND AGREE TO ABIDE BY THESE POLICIES. Date Patient signature (Guarantor)

2 DATE: / / 1500 E. Woolford Rd. Ste. #101 Show Low, AZ [Phone] (928) [Fax] (928) jcollins@hallfootandankle.com PATIENT INFORMATION FORM (PLEASE PRINT) SOCIAL SECURITY# PATIENT NAME: DATE OF BIRTH: / / AGE: SEX: M F LAST FIRST MI PREFERRED NICKNAME: MAILING ADDRESS: CITY/STATE: ZIP: HOME PHONE #: ( ) - WORK PHONE #: ( ) - CELL PHONE #: ( ) - MAY WE LEAVE A MESSAGE? PREFERRED METHOD OF CONTACT: YES NO TELEPHONE YES NO WHICH #? CELL HOME WORK YES NO HOW DID YOU HEAR ABOUT US? YES NO PHYSICIAN REFERRAL INTERNET FRIEND/RELATIVE PHONEBOOK PRIMARY LANGUAGE: ENGLISH SPANISH OTHER ETHNICITY: HISPANIC/LATINO NON-HISPANIC/LATINO DECLINED RACE: AMERICAN INDIAN/ALASKAN NATIVE ASIAN AFRICAN AMERICAN CAUCASIAN PACIFIC ISLANDER/NATIVE HAWAIIAN OTHER DECLINED DO YOU HAVE A LEGAL GUARDIAN OR HEALTHCARE POWER OF ATTORNEY? YES IF YES, NAME: RELATIONSHIP: PHONE #: ( ) - EMERGENCY CONTACT: RELATIONSHIP: PHONE #: ( ) - PRIMARY CARE DOCTOR: WHO REFERRED YOU TO US? PHARMACY: LOCATION: PHONE #: ( ) - IS THERE A FAMILY MEMBER OR OTHER PERSON YOU WOULD LIKE FOR US TO SHARE YOUR MEDICAL INFORMATION? NO YES NAME(S) WHO IS RESPONSIBLE FOR PAYMENT? NO RELATIONSHIP TO PATIENT? ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURANCE INFORMATION PRIMARY INSURANCE COMPANY NAME: POLICY HOLDER NAME AND SS#: EMPLOYER POLICY# GROUP # SECONDARY INSURANCE COMPANY NAME: POLICY HOLDER NAME AND SS#: POLICY# GROUP # DATE OF BIRTH DATE OF BIRTH

3 PATIENT NAME: DATE OF BIRTH: // PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE HOW OFTEN DO YOU TAKE? PLEASE LIST ALL PRIOR SURGERIES WITHIN THE LAST 10 YEARS: TYPE OF SURGERY DATE TYPE OF SURGERY DATE SOCIAL HISTORY MARITAL STATUS: SINGLE MARRIED PARTNERED SEPARATED DIVORCED WIDOWED USE OF ALCOHOL: NEVER NO LONGER USE HISTORY OF ALCOHOL ABUSE CURRENT USE - TYPE RARE OCCASIONAL MODERATE DAILY USE OF TOBACCO: NEVER CURRENT-EVERYDAY CURRENT SOME DAY FORMER UNKNOWN IF EVER SMOKE PACKS/DAY FOR YEARS CHEWING TOBACCO USE OF RECREATIONAL DRUGS: NEVER QUIT HOW LONG AGO? TYPE CURRENT USE - TYPE RARE OCCASIONAL MODERATE DAILY EMPLOYER: OCCUPATION: HOW MUCH ARE YOU ON YOUR FEET AT WORK? 10% 25% 50% 75% 100% DO OTHERS DEPEND UPON YOU FOR THEIR CARE? CHILDREN AGE(S) ELDERLY OR DISABLED FAMILY MEMBER OTHER PET(S) WHAT KIND? EXERCISE: NEVER RARE OCCASIONAL WEEKLY SEVERAL TIMES A WEEK DAILY TYPES OF EXERCISE/ACTIVITIES: FAMILY HISTORY DO YOU HAVE A FAMILY HISTORY OF: DIABETES /TYPE- CANCER HEART DISEASE HIGH BLOOD PRESSURE STROKE AMPUTATION RHEUMATOID ARTHRITIS OTHER ARE YOUR PARENTS AND/OR SIBLINGS LIVING: YES NO YOUR MEDICAL HISTORY ALLERGIES: NONE KNOWN ANESTHESIA TAPE MEDICATIONS FOODS LATEX SHELLFISH IODINE OTHER DO YOU HAVE ANY MEDICATION INTOLERANCES: PLEASE LIST:

4 PATIENT NAME: DATE OF BIRTH: // HAVE YOU EVER HAD ANY OF THE FOLLOWING? ACID REFLUX Y N DIABETES I II (CIRCLE) Y N NEUROPATHY Y N ANEMIA Y N FIBROMYALGIA Y N OPEN SORES Y N ANXIETY Y N GOUT Y N PNEUMONIA Y N ARTHRITIS Y N HEART ATTACK Y N POLIO Y N ASTHMA Y N HEART DISEASE/FAILURE Y N RHEUMATIC FEVER Y N BACK TROUBLE Y N HEPATITIS Y N SICKLE CELL DISEASE Y N BLADDER INFECTIONS Y N HIV+/AIDS Y N SKIN DISORDER Y N ABNORMAL BLEEDING Y N HIGH BLOOD PRESSURE Y N SLEEP APNEA Y N BLOOD CLOTS Y N KIDNEY DISEASE Y N STOMACH ULCERS Y N BLOOD TRANSFUSION Y N LIVER DISEASE Y N STROKE Y N BRONCHITIS/EMPHYSEMA Y N LOW BLOOD PRESSURE Y N THYROID DISEASE Y N CANCER Y N MIGRAINE HEADACHES Y N TUBERCULOSIS Y N DEPRESSION Y N MITRAL VALVE PROLAPSE Y N ARE YOU PREGNANT? Y N OTHER CONDITIONS: LIST: HEIGHT: WEIGHT: SHOE SIZE: ****WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY? WHERE IS THE PAIN/PROBLEM LOCATED? PLEASE MARK ON THE PICTURES BELOW. F B B I O O I

5 PATIENT NAME: DATE OF BIRTH: // HOW LONG AGO DID THIS PROBLEM FIRST START? DID YOUR PAIN OR PROBLEM: BEGIN ALL OF A SUDDEN DAYS / WEEKS / MONTHS / YEARS GRADUALLY DEVELOP OVER TIME HOW WOULD YOU DESCRIBE YOUR PAIN? NO PAIN SHARP DULL ACHING BURNING RADIATING ITCHING STABBING OTHER HOW WOULD YOU RATE YOUR PAIN ON A SCALE FROM 0 TO 10? (PLEASE CIRCLE) (NO PAIN) (WORST PAIN POSSIBLE) SINCE THE TIME YOUR PAIN OR PROBLEM BEGAN, HAS IT: STAYED THE SAME BECOME WORSE IMPROVED WHAT MAKES YOUR PAIN OR PROBLEM FEEL WORSE? WALKING STANDING DAILY ACTIVITIES RESTING DRESS SHOES HIGH HEELS FLAT SHOES ANY CLOSED TOE SHOE BAREFOOT WALKING RUNNING OTHER WHAT MAKES YOUR PAIN OR PROBLEM FEEL BETTER? WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM(INCLUDING OTC MEDICATION)? HOW HAS THIS PROBLEM AFFECTED YOUR LIFESTYLE OR ABILITY TO WORK? WAS THIS PROBLEM CAUSED BY AN INJURY? YES (DESCRIBE) DATE OF INJURY: NO IF YES, WAS IT A WORK-RELATED INJURY? YES NO ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: I ACKNOWLEDGE THAT, IF I ASKED, I WAS PROVIDED A COPY OF THE NOTICE OF PRIVACY PRACTICES FOR JARED A. HALL, DPM AND THAT I HAVE READ (OR HAD THE OPPORTUNITY TO READ IF I SO CHOOSE) AND UNDERSTOOD THE NOTICE. PRINT NAME OF PATIENT, PARENT OR GUARDIAN SIGNATURE AND DATE TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS. I HEREBY GIVE MY PERMISSION TO DR. JARED A. HALL TO ADMINISTER AND PERFORM PROCEDURES AS MAY BE NECESSARY IN THE DIAGNOSIS/TREATMENT OF MY FOOT/LEG CONDITION. I REQUEST THAT PAYMENT UNDER THE MEDICAL INSURANCE PROGRAM BE MADE TO JARED A. HALL, DPM, PLLC ON MY BEHALF. I ALSO AUTHORIZE THE RELEASE OF MY MEDICAL INFORMATION TO MY INSURANCE COMPANY IF NECESSARY. SHOULD IT BECOME NECESSARY TO REFER THE ACCOUNT TO A COLLECTION AGENCY FOR COLLECTION, THE UNDERSIGNED AGREES TO PAY A COLLECTION FEE OF SIXTY-FIVE PERCENT, AND COURT COSTS AS THEY ARISE. PRINT NAME OF PATIENT, PARENT OR GUARDIAN SIGNATURE OF DOCTOR IF OTHER THAN PATIENT, RELATIONSHIP TO PATIENT DATE SIGNATURE AND DATE