CRYSTAL CITY FOOT AND ANKLE CARE DR RONALD LOUCKS, DPM FAX Robert Thompson Ln, Festus, MO

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1 FAX Welcome/Welcome back to our office! Please fill out this paperwork COMPLETELY, each section must be completed in full, please. Even if you have been seen in our office previously, we will need all of this information updated to our new electronic medical record system. Since we must enter all the information BEFORE Dr Loucks is able to see you, we are asking that you return the paperwork to us as soon as possible to reduce your wait time in the office. You may: Fax it to (1) it to Or drop it by the office If these options are not possible, you will need to arrive minutes BEFORE your appointment time so we have time to enter the information into the computer before you see the doctor. As you fill out the papers, please note that regarding your medications, we need the NAME of the medicine, the STRENGTH, and also the dosage DIRECTIONS. For example: Aspirin 81mg 1 tablet daily. On your surgery list, we need your BEST guess of the date (at least the year). If your insurance requires a referral, it is your responsibility to obtain that and have it faxed to our office. Thank you for your cooperation. Sincerely, Lori Loucks/Daneen Buehler Office Manager/Billing Manager **If you are unable to keep your scheduled appointment for any reason, please call the office to cancel as soon as possible, so that we are able to fill that appointment with another patient. While we realize there are emergent situations in which we may need to consider an exception, our office policy for no shows or last minute cancellations is a $25 charge.

2 Please arrive by: FAX or Appt on, at Please complete this paperwork in full and bring with you to your appointment, Fax it to us at , or it to along with your insurance card & photo ID. If your insurance requires a referral, it is your responsibility to obtain that and have it faxed to our office. Thank you for trusting us with your medical care. Patients Name: First: Middle Last Date of Birth: Male Female Race: SSN: - - Address: City: State: Zip: Preferred phone: May we leave a message? Y N Alternate Phone: Marital Status:- Pregnant: yes no Employment status: Employer Name: Employer phone: List your Primary Care Physician: Phone: EXACT Date last seen by above PCP: (WE MUST HAVE THE EXACT FOR MEDICARE Patients) Pharmacy: Phone: Emergency Contact Phone Emergency address Relationship to patient ***If patient is a minor: Mothers name Phone: Fathers name Phone: Primary caregiver Relationship Phone Legal Guardian Relationship Phone Primary Insurance Co: ID# Insureds Name: (who carries the ins if other than patient) First : Middle Last Address: City: State: Zip: Phone number: Date of Birth: Male Female Insured relationship to patient : Self Spouse Dependant Other Secondary Insurance Co: ID# Insureds Name (who carries the ins if other than patient): First : Middle Last Address: City: State: Zip: Phone number: Date of Birth: Male Female Insured relationship to patient : Self Spouse Dependant Other SEE REVERSE SIDE

3 List any allergies to medications & type of reactions that resulted: OR CHECK no known drug allergies What brings you to the office today: Have you had a flu vaccine? Y N. If yes, approx. date? Have you had a pneumonia vaccine? Y N. If yes, approx. date? Please list ALL MEDICATIONS, with exact dosage/directions: MEDICATION DOSAGE & STRENGTH PRESCRIBING DOCTOR If additional medications, please attach a separate list including all of the above information Please list any immediate family medical history that may be related to your health issues: Indicate your tobacco use: NEVER Cigarettes How much? How long? Date quit Cigars How much? How long? Date quit Pipe How much? How long? Date quit Chewing tobacco How much? How long? Date quit Dipping tobacco How much? How long? Date quit Check Yes or No whether YOU have any of the following: ANEMIA Y N ANXIETY Y N ARTHRITIS Y N ASTHMA Y N BACK PROBLEM Y N CHF Y N COPD Y N CANCER Y N HIGH CHOLEST. y N DEMENTIA Y N DEPRESSION Y N DERMATITIS Y N DIABETES Y N GERD Y N GOUT Y N HEART DISEASE y N HIST. OF ALCOHOLISM Y N HIST. OF DRUG ABUSE Y N HIV y N HEPATITIS y N HYPERTENSION Y N KIDNEY DISEASE Y N HEART ATTACK Y N MIGRAINE Y N PNEUMONIA Y N STROKE Y N THYROID DISEASE Y N ULCER Y N OTHER

4 PLEASE LIST ANY AND ALL SURGERIES YOU HAVE HAD: None SURGERY APPROXIMATE I authorize release of any information concerning my (or my child s) healthcare, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor. I recognize my financial obligation of any coinsurance or deductible and non-covered services that may be required I understand that I will be responsible of all collection fees should my account become delinquent, necessitating collection procedures. I hereby authorize the processing of the Medical Insurance either by electronic or manual method by the listed provider above. This agreement will remain in effect until revoked by me in writing. A copy of this document is considered as valid as an original. PRINTED NAME I authorize transfer of my pertinent medical records from my Primary Care Physician to Crystal City Foot & Ankle Care, if required. And also for Crystal City Foot & Ankle Care to send medical records to my Primary Care Physician, when necessary. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES CRYSTAL CITY FOOT AND ANKLE CARE- RONALD LOUCKS DPM *You may refuse to sign this acknowledgement I,, have received a copy of this office s Notice of Privacy Practices. SEE REVERSE SIDE

5 FAX SIGNATURE ON FILE I hereby authorize the processing of the medical insurance either by electronic or manual method by the listed provider above. My signature authorizes payment of all major medical and/or surgical benefits to which I am entitled from the listed Insurer below to pay the listed provider assignee. I further authorize the assignee to release all medical and/or insurance claim information necessary to secure the payment(s). I recognize my financial obligation of any coinsurance or deductible, and non-covered services that may be required, and that I am ultimately responsible for my bill. I understand that I will be responsible for all collection fees should my account become delinquent, necessitating collection procedures. This agreement will remain in effect until revoked by me I writing. A copy of this document is considered as valid as an original. **IF MEDICARE Recipient: I request that payment of authorized Medicare benefits be made on behalf to Crystal City Foot and Ankle Care, Ronald J Loucks, DPM for any services furnished me by the listed physician/supplier. I authorize any holder of medical information about me to release to Medicare and its agents any information needed to determine these benefits payable to related services. I request payment of authorized Medigap benefits be made to this provider and also authorize any holder of medical information about me to release to the below named Medigap insurer any information needed to determine benefits payable for services from this provider. I understand my signature below requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Block 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare cases, the provider or supplier agrees to accept the charge determination of the Medicare Carrier as the full charge, and the patient is responsible for the deductible, coinsurance and the non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare Carrier. This agreement will remain in effect until revoked by me in writing. A copy of this document is considered as valid as an orginal. PRINTED NAME OF BIRTH

6 FAX We are located on the corner of Pounds Rd & Robert Thompson Ln DIRECTIONS TO OUR OFFICE From South/Desoto: Take 67 North to Hwy CC (go left) - 0.2mi Make a slight left onto Gamel Cemetary Rd - 0.9mi Stay straight onto Pounds Rd - 0.1mi Turn right on Robert Thompson Ln From Hillsboro: At Hwy 21, Take Hwy A 8.8mi Turn right onto Pounds Rd. Go to the 2 nd street on the left Robert Thompson Ln From North: Take Hwy 55 South to Hwy A (Exit 175) Make a right onto Hwy A 0.7mi Make a left onto Pounds Rd Go to the 2 nd street on the left Robert Thompson Ln From Crystal City: Take to Hwy A go 1.5mi Make a left onto Pounds Rd Go to the 2 nd street on the left Robert Thompson Ln SEE REVERSE SIDE

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