PATIENT INFORMATION. First Name: Middle Initial: DATE OF BIRTH: / / AGE: Gender: M F SSN: ADDRESS: CITY/STATE: ZIP:

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Geraldine Cole
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1 PATIENT INFORMATION First Name: Middle Initial: Last Name: DATE OF BIRTH: / / AGE: Gender: M F SSN: ADDRESS: CITY/STATE: ZIP: HOME PHONE #: ( ) - CELL PHONE #: ( ) - What is the best methd t reach yu? HOME PHONE CELL PHONE OCCUPATION: MARITAL STATUS: Single Married Divrced Partner Widwed Unknwn Legally Separated PRIMARY CARE PHYSICIAN: Date Last Seen: / / PCP PHONE & ADDRESS: RACE: American Indian r Alaska Native Asian Black r African American Native Hawaiian r Other Pacific White ETHNICITY: Nt Hispanic r Latin Hispanic r Latin PRIMARY LANGUAGE: Wh Referred Yu t Our Office? PHARMACY: LOCATION: PHONE #: ( ) - INSURANCE INFORMATION If yu have a cpay, etc., PLEASE NOTE THAT WE ONLY ACCEPT CASH OR CHECK AS FORMS OF PAYMENT. PRIMARY INSURANCE COMPANY INFORMATION SECONDARY INSURANCE COMPANY INFORMATION POLICY HOLDER INFORMATION POLICY HOLDER INFORMATION First Name: Last Name: Plicy Hlder s SSN: Plicy Hlder s DOB: Insured s Relatinship t Plicy Hlder: Self Spuse Gender: Male Female Child Other Address: City/State: Zip: Insurance Name: Member/Subscriber ID: Grup #: Effective Date: D yu have a cpayment? YES Amunt $ r NO Referral Required?: YES r NO First Name: Last Name: Plicy Hlder s SSN: Plicy Hlder s DOB: Insured s Relatinship t Plicy Hlder: Self Spuse Gender: Male Female Child Other Address: City/State: Zip: Insurance Name: Member/Subscriber ID: Grup #: Effective Date: D yu have a cpayment? YES Amunt $ r NO Referral Required?: YES r NO I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM AND HEREBY ASSIGN TO THE PHYSICIAN ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO MY DEPENDENTS OR MYSELF. I UNDERSTAND THAT IT IS AS A COURTESY THAT THE DOCTOR ACCEPTS MY INSURANCE FOR PAYMENT AND THAT IF FOR ANY REASON THEY DO NOT PAY MY BILL THAT I AM RESPONSIBLE. Patient s Signature: Initial Visit Date:

2 PATIENT HISTORY ALLERGIES: [ ] NONE KNOWN [ ] Adhesive Tape [ ] Anticagulant Therapy [ ] Aspirin [ ] Cdeine [ ] Demerl [ ] Idine [ ] Lcal Anesthetics [ ] Nvacain [ ] Penicillin [ ] Seafd [ ] Sulfa [ ] Other: [ ] MEDICATION ALLERGIES [ ] ANESTHESIA ALLERGIES [ ] FOOD ALLERGIES Have yu taken a flu sht this year? [ ] YES [ ] NO PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDING PRESCRIPTIONS, OVER-THE- COUNTER MEDS AND HERBAL SUPPLEMENTS): [ ] NONE NAME DOSE FREQUENCY HAVE YOU EVER HAD ANY OF THE FOLLOWING? (PLEASE CHECK) [ ] NONE [ ] AIDS/HIV [ ] CLAUDICATION [ ] HYPERTENSION [ ] PSYCHIATRIC PROBLEMS [ ] ALCOHOLISM [ ] CONGESTIVE HEART DISEASE [ ] HYPOTENSION [ ] PVD [ ] ALLERGIES [ ] CROHN S DISEASE [ ] IRRITABLE BOWEL SYNDROME [ ] RHEUMATIC FEVER [ ] ANEMIA [ ] DIABETES HbA1C level [ ] KIDNEY PROBLEMS [ ] RHEUMATIC HEART DISEASE [ ] ANGINA [ ] DIZZINESS/FAINTING [ ] LEFT VENTRICULAR SYSTOLIC DYSFUNCTION [ ] AORTIC ANEURYSM [ ] DVT [ ] LUPUS [ ] SCARLET FEVER [ ] APPENDICITIS [ ] EDEMA [ ] LYMPHEDEMA [ ] SEIZURES [ ] ARTERIOSCLEROSIS [ ] EMPHYSEMA [ ] MEASLES [ ] STDs [ ] ARTHRITIS [ ] EPILEPSY [ ] MULTIPLE SCLEROSIS [ ] STROKE [ ] ASTHMA [ ] FEMORAL POPLITEAL BYPASS [ ] MUMPS [ ] THROMBOPHLEBITIS [ ] BIRTH TRAUMA [ ] GANGRENE [ ] MURMUR [ ] THYROID DISORDER [ ] BRONCHITIS [ ] GERD [ ] MYOCARDIAL INFARCTION [ ] TUBERCULOSIS [ ] CANCER [ ] GLAUCOMA [ ] NEUROPATHY [ ] TYPHOID FEVER [ ] CARDIAC ARREST [ ] GOITER [ ] OSTEOPOROSIS [ ] ULCERS [ ] CARDIAC ARRHYTHMIAS [ ] GOUT [ ] PACEMAKER [ ] VARICOSE VEINS [ ] CARDIAC DISEASE [ ] HEADACHES [ ] PHLEBITIS [ ] VENEREAL DISEASE [ ] CARDIOMYOPATHY [ ] HEPATITIS [ ] PLEURISY [ ] WEIGHT CHANGE [ ] CELIAC DISEASE [ ] HERNIA [ ] PNEUMONIA [ ] WHOOPING COUGH [ ] CHICKEN POX [ ] HERPES [ ] POLIO [ ] OTHER: [ ] CHRONIC HEART DISEASE [ ] HYPERLIPIDEMIA [ ] Currently PREGNANT? PLEASE LIST ALL PRIOR SURGERIES: [ ] NONE TYPE OF SURGERY DATE

3 SOCIAL HISTORY SMOKING STATUS: [ ] NEVER [ ] FORMER [ ] SOMETIME [ ] EVERYDAY TOBACCO USE: [ ] NEVER [ ] FORMER [ ] SOMETIME [ ] EVERYDAY PODIATRIC HISTORY What is yur SHOE SIZE: and WEIGHT: and HEIGHT: What is yur main cncern tday? D yu have any ther ft/ankle/alignment cncerns which require attentin? Please list. When did yur main cncern begin? Where is the area f cncern? Please be very specific. Describe any pain, limitatins in walking/standing/activity and/r disability. Is the pain Burning Thrbbing Sharp Dull Aching Other What causes the pain r makes it wrse? Is there any ther pertinent backgrund infrmatin? N Yes (Please explain.) Was it caused by an injury? N Yes (Please explain.) Des anything else affect the prblem? N Yes (Please explain.) Is there anything else that yu can tell us that will assist us? FOR MEDICAL STAFF ONLY: FOOT EXAM: [ ] TRUE [ ] FALSE BLOOD PRESSURE:

4 HIPAA OFFICE PROCEDURES SHORT FORM This is the shrt frm that is required by the federal gvernment fr ALL physicians and healthcare prviders as f April 14 th, This ntice describes hw medical infrmatin abut yu may be used and disclsed, and hw yu can get access t this infrmatin. Yu may request at any time t read the mre detailed LONG frm versin f ur ffice s privacy plicy. This requirement is detailed in the HIPAA (Health Insurance Prtability and Accuntability Act), fr mre infrmatin n HIPAA, yu can visit the fficial website at If yu have any questins abut this Ntice, please cntact ur Privacy Cntact, Dr. Ellit Diamnd. HIPAA Cnsent Shrt Frm as per Federal HIPAA Law # Please review the fllwing infrmatin in its entirety, and sign at the bttm. There may be times ur ffice may need t use yur private health infrmatin (PHI) t cntact yu either by phne, e- mail r mail in regards t issues as: Appintment Reminders, Infrmatin abut treatment & treatment alternatives Insurance infrmatin and/r billing issues, etc. Cards (such as birthday, get well, etc.), thank yu ntes fr referrals Other health infrmatin that may be f interest t yu, including a health newsletter In ur attempt t cntact yu, we may nt get yu directly. This means that cntact may be either thrugh a letter, pstcard, r vice mail (answering machine). Shuld yu have a reasn t exclude ne f these methds, please let a member f ur staff knw yur request. Hwever, ur ffice des reserve the right t cntact yu by any means necessary if we feel that it is a warranted medical emergency. Please submit any exclusin frm cntact t ur ffice in writing, s we can make this request a permanent part f yur health file. In rder t achieve a mre related and family apprach t healthcare, ur ffice chses t practice in an pen style f treatment. In mst cases exam and treatment rms are ften left pen except where mdesty is apprpriate. If at any time, yu wuld like t increase yur privacy by being treated in a sealed rm, r if there are issues yu wuld like t discuss in a mre secure and private fashin, please ask a member f ur staff prir t yur treatment r cnsultatin. Additinally, in rder t keep a mre persnal atmsphere, ur receptin space is pen air t the public. We chse nt t emply a privacy shield r glass windw s ur patients feel mre at hme and have direct cntact with the staff shuld they need it, rather than having t knck and feel intrusive. If at any time yu wuld wish t cmmunicate with the staff privately, r have the staff exclusively cmmunicate t yu r abut yur PHI in a mre secure lcatin, please make the staff aware f this request. I acknwledge that nce I sign this cnsent frm, that I will agree t the terms and cnditins as set dwn by Federal HIPAA Law. Shuld yu wish t read the LONG frm f ur ffice privacy plicies, please make this request befre signing this frm. Please see a member f ur privacy team if yu have any questins r need assistance in cmpleting this frm. Printed Patient Name: Signed: Date:

5 PATIENT FINANCIAL POLICY We are dedicated t prviding the best pssible care and service t yu. Yur cmplete understanding f ur financial plicies is an essential element f yur care and treatment. Please sign at the bttm f this cntract in agreement f the terms and cnditins f ur financial plicy. If yu have any questins, please discuss them with ur ffice manager. PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED. WE ACCEPT CASH OR CHECK ONLY. As a curtesy, we will file yur insurance claim fr yu if yu assign the benefits t the dctr. In ther wrds, yu agree t have yur insurance cmpany pay the dctr directly. We will als try t keep track f necessary dcumentatin, referrals, and pre-certificatins yu will need t be treated at ur ffice. Hwever, as ur patient, yu are ultimately respnsible fr all authrizatins/referrals needed t seek treatment in this ffice. Yu must infrm the ffice f all insurance changes and pre-authrizatin and/r referral requirements. In the event the ffice is nt infrmed, yu will be respnsible fr any charges denied. Unless ther arrangements have been made in advance by yu, r yur health insurance carrier, payment fr ffice services are due at the time f service. If nt cvered by insurance, payment is expected in full at the time f service. Pre-certificatin fr treatments may r may nt be dne as a curtesy t yu; hwever, it is ultimately yur respnsibility t ntify yur insurance carrier prir t any treatment. Yur insurance plicy is a cntract between yu and yur insurance cmpany. If yur insurance cmpany des nt pay the practice within a 90 day perid fllwing an ffice visit, yu will be respnsible fr any unpaid balance. We have made prir arrangements with mst insurers and ther health plans t accept an assignment f benefits. We will bill thse plans with which we have an agreement and will nly require yu t pay the c-pay/c-insurance/deductible at the time f service. Usual and custmary rates may be different frm charges fr services rendered. Yu will be respnsible fr payment f any differences withut regard t insurance determinatin f usual and custmary r similar type cverage by insurance carrier(s). In additin, yu agree nt t delay n payment due t persnal bankruptcy and r attrney advisement t nt pay n the accunt nr any curt actin including and nt limited t wrker s cmpensatin cases r injuries. All health plans are nt the same and d nt cver the same services. In the event yur health plan determines a service t be "nt cvered," r yu d nt have an authrizatin/referral/pre-cert, etc., yu will be respnsible fr the cmplete charge. We will attempt t verify benefits fr sme specialized services; hwever, yu are respnsible fr charges f any service rendered. Patients are encuraged t cntact their insurance fr clarificatin f plan benefits prir t services rendered. IF YOUR INSURANCE CONSIDERS OUR PROVIDER AS OUT OF NETWORK, THEN THEY MAY SEND YOU PAYMENTS DIRECTLY, IT IS YOUR RESPONSIBILITY TO FORWARD OUR OFFICE THOSE CHECKS WITHIN 30 DAYS. THOSE CHECKS ARE PAYMENT TO OUR PROVIDER FOR SERVICES RENDERED AT YOUR VISIT(S). If yu are Medicare eligible, a claim will be filed n yur behalf fr cvered services. The respnsibility fr payment f services rendered t any dependent children whse parents are divrced rests with the parent wh seeks treatment. Any curt rdered respnsibility judgment must be determined between the individuals invlved withut the inclusin f ur ffice. Any credit balances n a patient s accunt will be applied t any unpaid balances. Past due accunts are subject t cllectin prceedings. All fees including, but nt limited t cllectin fees, attrney fees and curt fees shall becme yur respnsibility in additin t the balance due this ffice. There is a service fee f $30.00 fr all returned checks. Yur insurance cmpany des nt cver this fee. A fee may be charged if yu fail t cancel yur appintment within 24 hurs and/r d nt shw fr yur appinted time. In additin, all unpaid balances 91 days past due will incur interest f 1.5% per mnth which will be applied frm day 31 frm the date f service until the balance is paid in full. Thank yu fr yur understanding ur Financial Plicy. I authrize treatment f the persn named belw and agree t pay all fees and charges fr me and my family shwn by statements prmptly upn presentatin theref unless credit arrangements are agreed in writing. Charges shwn by statement are agreed t be crrect and reasnable unless prtested in writing within 30 days f billing date. I fully understand all terms and cnditins, and this has been fully explained t my / ur satisfactin, and I / we have cmpletely read this financial agreement and authrizatin fr treatment. AUTHORIZATION AND ASSIGNMENT I authrize Dr. Ellit Diamnd's ffice t release medical infrmatin that may be necessary t request claim reimbursement frm insurance cmpanies t prcess my claim(s) in additin t the previsins f the separate HIPPA frm executed by the patient/parent/guardian. I als authrize claim payments including majr medical benefits t be made t Dr. Ellit Diamnd. I understand that I will be credited any verpayment. I understand that I am respnsible fr payment f my accunt and if this assignment r claim is rejected, it will be my respnsibility t pay any unpaid charges in full within 90 days f the riginal date f service. I authrize Dr. Ellit Diamnd's ffice t secure whatever infrmatin regarding any claim t any insurance cmpany he feels necessary in assisting me in reaching its settlement r understanding f certain aspects f its settlement. This authrizatin and assignment may be revked by me at any time by a written ntice. By signing belw, I agree t cmply with the abve stated requests and respnsibilities, as they pertain t me, as a patient f Dr. Ellit Diamnd s ffice. I agree a phtcpy f this fr may be used in lieu f the riginal. Date: / /

Main Phone #: ( ) - Secondary Phone # :( ) -

Main Phone #: ( ) - Secondary Phone # :( ) - Patient Infrmatin Email: Male r Female: SS# - - DOB: / / Address: Main Phne #: ( ) - Secndary Phne # :( ) - (Circle One): Married Single Divrced Widwed Name f Spuse r Guardian: In Case f Emergency: Whm