Medicine and Surgery of the Foot PATIENT INFORMATION PERSON RESPONSIBLE FOR PAYING THE BILL FAMILY PHYSICIAN INFORMATION HEALTH INSURANCE INFORMATION

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1 PATIENT REGISTRATION Thank you for choosing our office! Please complete all pages. Patient Name: PATIENT INFORMATION Home Address: City: State: Zip: Sex: S S#: Marital Status: S,M,O or minor Home Phone: Cell Phone: DOB Employer Name/Occupation Race Language Work Phone: Name: PERSON RESPONSIBLE FOR PAYING THE BILL SS#: Home Address: City State Zip Employer Name: Name: Work Phone: FAMILY PHYSICIAN INFORMATION Phone: Did your family physician refer you to this practice? What is the date you last saw this doctor? Insurance Carrier: Policy Number: Group Number: Effective Date: CoPay: Policyholder Name: Date of Birth: Sex: Patient Relationship: Emergency Contact: HEALTH INSURANCE INFORMATION PRIMARY INSURANCE SECONDARY INSURANCE EMERGENCY INFORMATION TERTIARY INSURANCE Emergency Contact s Phone #: Emergency Contact s Relationship to Patient: 1

2 Reason for today s visit: REASON FOR TODAY S VISIT Former Podiatrist or previous treatment FAMILY HISTORY Please indicate which of your relatives (living or deceased) have had any of the following diseases: Cancer: Heart Trouble: Kidney Disease: Strokes: Diabetes: High Blood Pressure: Arthritis: Other: MEDICAL HISTORY Have you ever had any of the following? Please CIRCLE all those that apply: Allergies/Hay fever Anemia or abnormal bleeding Depression Diabetes Liver Disease / Hepatitis Lungs (Pneumonia, T.B., etc.) Do you smoke? How Much? Arthritis/Fibromyalgia Fracture history Mental / Emotional Disease Do you take any illegal drugs? Asthma Gall bladder or Gall stones Neuropathy Back Pain Cancer Glaucoma Gout Shortness of Breath Skin problems Do You drink alcohol? How much? Chest Pain Heart Problems Stomach Trouble Other illnesses or problems Cholesterol High Blood Pressure Stroke Circulation Problems HIV/AIDS Thyroid problems Are you pregnant? YES or NO Kidney disease or stones Trouble w/ vision SURGICAL HISTORY Please list all serious illnesses, operations, and other hospitalizations you have experienced, please include dates: 2

3 CURRENT LIST OF MEDICATIONS NAME OF DRUG Dosage What is it for? Drug Allergies Other Do you have any other medical problems or concerns we have not asked? Name of Pharmacy Address Phone number How did you hear about us? To the best of my knowledge, all of the preceding answers and information are true and correct. If I ever have any change in my health I will inform the doctors at the next appointment without fail. Date Signature of Patient, Parent or Guardian 3

4 OFFICE POLICIES OF CAROLINA We are committed to providing you with the best possible care. If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. (PLEASE BE SURE TO PROVIDE ALL INSURANCE INFORMATION AT CHECK IN) In order to achieve these goals, we need your assistance and understanding of our payment policy. At every office visit we must verify your identify with a State issued picture ID. Payment for service is due at the time the service is rendered unless payment arrangements have been approved in advance by our office. We accept cash, in state checks, Mastercard or Visa. We must emphasize that as medical care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients. ALL CHARGES ARE YOUR RESPONSIBILITY FROM THE DATE THE SERVICES ARE RENDERED. Returned checks fee is $25 and balances older than 30 days may be subject to additional collection fees and interest charges of 1.5% per month. A $20 fee will be charged for broken appointments and appointments cancelled less than 24 hours in advance. Surgeries and special procedures may require a deposit to be collected prior to the procedure. A missed/broken/ cancelled procedure less than 24 hours prior to your pretesting appointment may result in a $50 fee or a % of the scheduled procedure. You must realize, however, that: 1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. 2. Not all services are a covered benefit in all contracts. You are responsible for any fees not covered under your policy, as well as co-pays and deductable amounts. 3. If you have not provided us with your most current insurance information at check in and your claim is denied, you will be responsible for the payment in full. We will only file your insurance one time. 4. Your insurance referrals, authorizations and eligibility dates, and/or TRICARE eligibility, REFERRALS and authorization service dates are YOUR responsibility. If your insurance expires or your TRICARE authorization expires, you must obtain and provide us with new insurance information and/or a new TRICARE authorization. 5. There is a fee ($10-$20) dollars for completion of FMLA forms, disability forms and copies of medical records. If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE do not hesitate to ask us. We are here to help you. I have read and fully understand the above policies, and by signing this document acknowledge that I will comply with these policies. Date Signature 4

5 MEDICARE CERTIFICATION: The information provided by me in applying for payment for Social Security benefits is true and correct. I authorize the physician who treats me, to release information from my medical record to the Social Security Administration and/or the Medicare program or its intermediate carriers, or to the Professional Standards Review Organizations for processing of claims for medical benefits. I request that payment of authorization benefits be made directly to my physician treating me, on my behalf. Medicare regulations require that I am informed in advance of any service that may not be covered. The following services may not be covered: ROUTINE FOOT CARE: The trimming, cutting or debridement of corns, nails and calluses is not a covered service. Exceptions to the rule are: patients with peripheral vascular disease that are being treated by their primary physician for this condition. Medicare will pay for nail debridement for patients who suffer from vascular disease every 61 days. If you receive treatment more frequently, you will be responsible for the services rendered. OTHER SERVICES: Post Operative shoes, supplies such as bandages, medications, and shoe inserts, prescription orthotics and custom orthopedic shoes, lab handling fees. Signature 5