McKenzie-Hastings Institute For Foot & Ankle Surgery Patient Registration

Transcription

1 McKenzie-Hastings Institute For Foot & Ankle Surgery Patient Registration Patient Name: Gender: Birthdate: Social Security: Home Phone: Cell: Work: Pharmacy: Location: Phone: Responsible Party (if other than patient): Home Phone: Cell: Work: Employer Name: Occupation: Primary Insurance: Effective Date: Group #: ID #: Policy Holder s Name (if other than patient): Secondary Insurance: Effective Date: Group #: ID #: Policy Holder s Name (if other than patient): Tertiary Insurance: Effective Date: Group #: ID #: Policy Holder s Name (if other than patient): Emergency Contact: Relationship: Home Phone: Cell: Work:

2 When confirming your appointment, may we leave a message on your machine/voic ? YES NO Please arrive 15 minutes prior to your appointment. We ask for a minimum of 24-hour notice for the canceling of your appointment. If you do not show for your scheduled appointment or cancel within the 24-hour notice, there will be a charge of $ Please sign below you acknowledge that the above information you provided is both accurate, complete, and up-to-date. McKenzie-Hastings Institute For Foot & Ankle Surgery HIPPA Policy Acknowledgement I acknowledge that I have been given the opportunity to read, review, and/or received paper copies of the Notice of Privacy Practices concerning protected health information (PHI). I give permission to the person(s) listed below- such as a spouse, parent/child, legal guardian, healthcare proxy, medical director, or power of attorneyto receive protected PHI or other authorization. I understand this form is legally binding and that I may revoke at any time by submitting my request to change, add, or terminate such permission in writing. Please return forms to: mhifeet@yahoo.com Fax: Mail: MHI, 1520 Breezeport Way, Suite 100, Suffolk, VA Or just bring them with you to your first appointment.

3 McKenzie-Hastings Institute For Foot & Ankle Surgery Medical Information Patient Name: DOB: Are you currently diabetic? YES or NO Primary Doctor: Phone Number: Name of Doctor that referred you to this office: SURGERY: Name of Surgery Year of Surgery Complication? (if yes, please define) FAMILY HISTORY (check all that apply): Mother Father Grandparents Siblings Children Anesthesia complication Bleeding disorder Cancer (specify type) Diabetes Epilepsy Glaucoma Heart disease High blood pressure Kidney disease Mental illness Osteoporosis Stroke Thyroid disease SOCIAL HISTORY & LIFESTYLE: Alcohol? YES or NO Recreational drugs? YES or NO Caffeine? YES or NO Daily amount? Daily amount? Daily amount? Type? Type? Type? Employer: Do you exercise weekly? YES or NO Job Title: What family members live with you? Smoking (check one): Non-smoker (never or <100 cigarettes in a lifetime) Previous smoker (quit date: ) Current smoker (1-3 cigarettes per day) Current smoker (up to one pack per day) Current smoker (one to two packs per day) Current smoker (two or more packs per day)

4 MEDICATIONS: *Please follow the example below, listing the SPECIFIC medication/strength/dose/diagnosis that is treated by the medication. MEDICATION STRENGTH HOW OFTEN DIAGNOSIS (WHY YOU TAKE MEDICATION?) Example: Lamisil 250 mg Once daily fungal toenails Any non-prescription therapies like vitamins or fish oil? PLEASE LIST SPECIFIC DOSAGE: Circle any other medical conditions that you have, but DID NOT list in the chart above (you are NOT currently taking medications for these): Anemia Ankle swelling Arthritis (osteoarthritis) Arthritis (rheumatoid) Arthritis (psoriatic) Asthma Bleeding disorder Blood clots Bowel disease Cancer- type: COPD Depression Diabetes Diphtheria Epilepsy Frequent infections Glaucoma Gout Heart disease Heart murmur Hernia High blood pressure High cholesterol HIV/AIDS Kidney disease Liver disease Lymphedema Measles Mental illness Migraines Mitral valve prolapse Mumps Rubella Scarlet fever Skin disease Sleep apnea STD- type: Stomach ulcers Stroke Thyroid disorder Varicose veins

5 ALLERGIES: NO KNOWN DRUG, FOOD, OR ENVIRONMENTAL ALLERGIES DRUG ALLERGIES Name of Drug Location of Reaction (e.g. skin, local site, abdominal, systemic) Specific Reaction (e.g. rash, swelling, hives, tongue swelling, cramping, shortness of breath) Severity of Reaction (very mild, mild, moderate, or severe) Example: penicillin systemic tongue swelling severe FOOD ALLERGIES Name of Food Location of Reaction Specific Reaction Severity of Reaction Example: dairy abdominal cramping mild ENVIRONMENTAL ALLERGIES Name of Allergen Location of Reaction Specific Reaction Severity of Reaction Example: dust localized sneezing very mild

6 McKenzie-Hastings Institute For Foot & Ankle Surgery Financial Policy Patient Name: Birthdate: 1. Payment is due at the time of service unless arrangements have been made in advance by your carrier. We accept cash, check, Visa, MasterCard and Discover. 2. Keep in mind that your insurance policy is a contract between you and your insurance company. As a service to you, our billing company will file your insurance claim if you assign the benefits to your doctor. If your insurance company does not pay the practice within a reasonable period, the practice will look to you for payment. If we later receive a check from your insurer, we will refund any overpayment to you. 3. We have made prior arrangements with many insurance companies and other health plans to accept an assignment of benefits. Our billing company will bill your insurance company, per your contract with your insurance company, you will be required to pay your copayment at the time of your visit. 4. If you have not met your deductible, you are required to pay $ prior to your initial visit with the doctor. 5. If you are a self-pay patient with no insurance, you are required to pay $ prior to your initial visit with the doctor. This is a down-payment on your account only. As a courtesy to you, all additional fees will be billed to you by our billing company. 6. If you are insured by a plan that we do not have a prior arrangement with, we will prepare and send the claim for you on an unassigned basis. This means the insurer will send the payment directly to you. Therefore, our charges for your care are due at the time of service. 7. Not all insurance plans cover all services. In the event your insurance plan determines a service not to be covered, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our billing company. 8. We will bill your insurance company for all services provided in the hospital. You are responsible for any balance due. 9. I authorize the release of any medical information to process my insurance Claims. I authorize and request payment of medical benefits directly to Dr. Heather McKenzie or Dr. Charles Hastings. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that an electronic or photocopy of this form may be used in place of the original. I accept full financial responsibility for all expenses of collection, if necessary, including the 33 1/3 % of any attorney fees and court costs. I have read and understand the practice s financial policy and agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.