PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)

Transcription

1 PATIENT INFORMATION Patient s Full Name: (First) (Middle) (Last) Birth date: Age: Race: Sex: [ ] Female [ ] Male Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed SS# Address: City: State: Zip: Home #: ( ) Work #: ( ) Cell #: ( ) Patient Employed by: Occupation: How Long: Employer s Address: Spouse s Name: SS# Cell Phone: ( ) Spouse Employed by: Occupation: How Long: Employer s Address: Any Immediate Family Member who was a Patient in Our Office: Person Responsible for Your Bill: Relationship: Billing Address (if other than above): Phone: ( ) Name of Primary Insurance Company: Policyholder s Name: Social Security # Employer: Group # Name of Secondary Insurance Company: Policyholder s Name: Social Security # Employer: Group # WHOM MAY WE THANK FOR SENDING YOU TO OUR OFFICE? I authorize Dr. Jane Graebner, Dr. Drew Belpedio, and Dr. Martha Anderson to furnish my insurance company (or Medicare) with all necessary information regarding my present illness or injury. I also authorize payment of medical benefits to Foot and Ankle Wellness Center. for medical services or supplies provided. I also authorize your office to obtain copies of test results as needed. A photo static copy of this authorization shall be considered as effective and valid as the original. Signature of Patient (or Guardian): Date: Address: Do you check often? [ ] Yes [ ] No BY WHAT NAME DO YOU WISH TO BE ADDRESSED?

2 Patient s Name: Occupation: REASON FOR VISIT Please describe your present foot or ankle concerns, problems, or symptoms: Have you ever seen a podiatrist before? Yes No (please circle) If yes, for what reason? (please include who and when): When was your last physical exam? MEDICAL HISTORY Family Dr. first and last name: Phone: ( ) 1. Are you currently under medical treatment? Yes No If yes, for what: 2. Have you ever had an operation especially pertaining to the legs, ankles, or feet? Yes No If yes, please describe: Pacemaker/Defibrillator (circle) Yes No Heart or leg stents (circle) Yes No Bypass surgery (heart or legs)(circle)yes No Hysterectomy Yes No Gall Bladder Yes No Appendix Yes No Orthopedic Yes No Catheterization Yes No Joint replacement Yes No Tonsils Yes No Gastric bypass or lap band (circle) Yes No Foot/Ankle surgery Yes No 3. Are you currently taking any prescription or over the counter medications? Yes No If yes, please list the name of the medication and the reason for taking: (or bring an updated list) Name of Medication/Dosage/When Taken Reason for Medication

3 MEDICAL HISTORY CONTINUED 4a. Do you smoke? Current Former Never 4b. Do you use any illegal drugs? Yes No 5a. Do you use alcohol? Yes No 5b. Are you: Married Single Divorced Widowed 6. Has any member of your immediate family been treated for the following: (please circle) Arthritis Yes No Heart Disease Yes No Cancer Yes No High Blood Pressure Yes No Diabetes Yes No 7. Have you ever had the following: (please circle) Anemia (low blood count) Yes No Kidney Disease Yes No Asthma Yes No Liver Disease Yes No Herniated disc Yes No Low Blood Pressure Yes No Spinal stenosis Yes No Migraine Headaches Yes No Blood Clots Yes No Mitral Valve Prolapse Yes No Peripheral arterial disease Yes No Multiple Sclerosis Yes No Acid Reflux Yes No Osteoarthritis Yes No Cancer Type: Yes No Muscular Dystrophy Yes No Chemotherapy Yes No Phlebitis Yes No Chronic Fatigue Syndrome Yes No Sleep Apnea Yes No Lupus Yes No Polio Yes No Diabetes How long? Yes No Blindness Yes No Emphysema Yes No Rheumatic Fever Yes No Epilepsy Yes No Rheumatoid Arthritis Yes No Fibromyalgia Yes No Psoriasis Yes No Glaucoma Yes No Hard of Hearing Yes No Gout Yes No Eczema Yes No Hardening of Arteries Yes No Stroke Yes No Heart Murmur Yes No Low Thyroid Function Yes No Heart Disease Yes No Tuberculosis Yes No Hepatitis A B C D Yes No Stomach Ulcer Yes No High Blood Pressure Yes No Varicose Veins Yes No HIV/AIDS Yes No Other:

4 MEDICAL HISTORY CONTINUED 8. Have you had any allergic reactions to the following: (please circle) Adhesive Tape Yes No Local Anesthetics (Novacaine) Yes No Aspirin Yes No Penicillin Yes No Codeine Yes No Sulfa Yes No Iodine Yes No Other Yes No Latex Yes No Please explain: 9. Do you have or are you subject to: (please circle) Burning Pain/Tingling/Numbness Yes No Foot/Leg Cramps at Night Yes No Chronic Infections Yes No Nervousness Yes No Fainting Yes No Prolonged Bleeding Yes No Leg/Foot Pain at Rest Yes No Swelling of Legs Yes No Foot/Leg Cramps When Walking Yes No Calf pain Yes No Circulatory Problems Yes No Bleeding Tendency Yes No Shortness of Breath Yes No Shortness of breath when active Yes No Previous MRSA or VRE infection Yes No Fever/Chills Yes No Chest pain Yes No Nausea/Vomiting Yes No Bleeding/Clotting disorder Yes No Back pain Yes No Cold feet Yes No Balance problems Yes No 10. Primary Pharmacy and Location I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. SIGNATURE DATE

5 FINANCIAL POLICY Full payment is expected on the day medical services are provided unless you have health insurance coverage with a plan that we have a written agreement. Then you are responsible to pay your: *DEDUCTIBLE: An amount you must pay first out of your own pocket each year before your insurance will pay for any services *CO-PAY: An amount you must pay before each visit to a doctor *CO-INSURANCE: An amount which is usually a percentage of the fee that your insurance company expects you to pay We will copy the front and back of your insurance card at your initial visit. We expect you to inform us of any change in coverage that may occur and provide us with an insurance card at that time. If you have two medical insurance plans, it is your responsibility to inform us which plan is your PRIMARY (first) coverage and which plan is your SECONDARY (second) coverage. You are expected to inform us if one (or both) insurance plans change or are no longer effective. Our financial policy offers you several payment options. You may use CASH, CHECK, CREDIT CARD, or a pre-approved EXTENDED PAYMENT PLAN which will assess an annual finance charge of 12% accrued monthly with a $1.00 minimum per month. We mail your insurance claim within one week of your services. If your insurance company has not responded within 3 months, we will assume you have received the check. A statement will be mailed from our office and it will then be your responsibility to pay the balance using one of the approved payment methods. If you have not heard from your insurance company, we suggest you call them and inquire as to the status of your claim. We will be glad to assist you in getting your insurance company to pay, but your bill in our office is ultimately your responsibility. Some insurance plans require a referral from your primary care physician. You are responsible for obtaining this referral prior to your visit or full payment will be expected for the medical services rendered. I have read this financial policy and understand it fully. Patient or Guardian Signature Date A copy of this agreement will be provided upon your request.

6 CONSENT FOR RELEASE OF INFORMATION BY TELEPHONE You may contact me at the following: HOME: YES NO (Please circle) If yes, what is your home telephone number? ( ) WORK: YES NO (Please circle) If yes, what is your work telephone number? ( ) CELL PHONE: YES NO (Please circle) If yes, what is your cell phone number? ( ) Are we permitted to give information about your foot/ankle condition (I.e. test results) to family members or others? YES NO (Please circle) If yes, please list any family members or other individuals we may release information to: Many times when calling, we reach an answering machine or voic . Are we allowed to leave a DETAILED message regarding your foot/ankle condition (i.e. test results)? YES NO (Please circle) PATIENT ACKNOWLEDGMENT FORM NOTICE OF PRIVACY PRACTICES I have received a copy of Dr. Jane Graebner s Notice of Privacy Practices. Patient Signature: Date Signed: I was offered a copy of Dr. Jane Graebner s Notice of Privacy Practices, but declined it. Patient Signature: Date Signed: A good faith effort was made to provide a copy Dr. Jane Graebner s Notice of Privacy Practices to this patient and to obtain acknowledgment. Patient ACCEPTED / DECLINED the Notice and refused or was unable to sign this acknowledgment. Dr. Jane E. Graebner s Employee Name: Employee Signature: Date Signed: