Brazos Valley Foot Care, PA

Transcription

1 Brazos Valley Foot Care, PA Brian Abbey DPM Eduardo Orihuela DPM Robert Aguilar DPM Julie Albert DPM Tyler Kearney DPM PATIENT INFORMATION First Name: Middle Initial: Last Name: Gen: Jr. Sr. Date of Birth: Gender: Male or Female SS# Street Address: City: State: Zip Code: Home Ph: Work Ph: Cell Ph: Ethnicity: Hispanic or Latino Non Hispanic or Latino Declined Language: English Spanish Other Race: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Marital Status: Divorced Legally Separated Married Single Unknown Widowed Student Status: Full Time Student Not a Student Part Time Student Employment Status: Employed Full Time Employed Part Time Not Employed Employer Name: Legal Representative (If a minor, who is responsible for payment): Name Date of Birth Phone Address City State Zip Code How were you referred to our office? Direct Mail Returning/Established Patient Insurance Internet Newspaper Other Patient (Referral from another patient) Radio TV Yellow Pages Provider Referral, List Referring Provider Primary Care Physician: Date Last Seen: Emergency Contact: Emergency Phone: Relation: Preferred Method of Contact: Phone Mail SMS With whom may we leave messages? Patient only Patient and/or Spouse Anyone answering the phone Primary Insurance: Subscriber Name: DOB: Insurance Number: Group Number: Secondary Insurance: Subscriber Name: DOB: Insurance Number: Group Number: I certify that the information given above is true and correct. I understand that it is my responsibility to notify Brazos Valley Foot Care, PA of any changes to the above information. Patient or Guardian Signature Date

2 HISTORY & MEDICAL INFORMATION Patient Name Podiatrist Name Primary Care Physician: Phone: City/State: Date of last visit and/or next visit: Diabetic Physician: Phone: City/State: Date of last visit and/or next visit: Height: Weight: Shoe Size: Blood Pressure: / / Have you received the influenza vaccine in 2015? Yes No Are you diabetic? Yes No If yes, what is your Hemoglobin A1C Level? Greater than 9% Less than 7% between 7-9% If diabetic, do you have kidney disease? Yes No If yes, do you? Receive dialysis Take an enzyme inhibitor Reason for visit (explain your foot/ankle problem): When did pain/discomfort begin? Describe pain/discomfort: Burning Numbness Sharp Other: What makes pain/discomfort better? What makes pain/discomfort worse? Previous treatment received for above condition(s)? Yes No If yes, list type of treatment/when received: Preferred Pharmacy: Name Location City State Phone List all current medications/vitamins, dosage, frequency & route of administration: No Current Medications/Vitamins List any allergies to medications: No Known Allergies Past Medical History: (Please check the conditions below that apply to your medical history) Anemia Gout High Blood Pressure Neurologic Disorder Thyroid Disorder Bleeding Disorder(S) Heart Disease Kidney Disease Prostate Disorder Stroke Cancer Hepatitis Lung Disorder Osteoarthritis Other: Diabetes High Cholesterol Mitral Valve Prolapsed Other Arthritis Epilepsy HIV/Aids Nerve Disorder Rheumatic Fever No Past Medical History Surgical History: (Please list previous surgeries/dates) None Social History: (Please check the below conditions that apply to your social history) Tobacco Use If yes, smoking status: Light Heavy Former Unknown Alcohol Use Caffeine Use Drug Use (Recreational, IV) None of the above Family History: (Please check the below conditions that apply to your family history and relationship(s) of members who have had problems) Bleeding Disorder (Mother / Father) Heart Disease (Mother / Father) Mental Illness (Mother / Father) Cancer (Mother / Father) High Blood Pressure (Mother / Father) Rheumatology (Mother / Father) Diabetes (Mother / Father) Kidney Disease (Mother/Father) Stroke (Mother/Father) Other: No Known Family History

3 REVIEW OF SYSTEMS Patient Name: Podiatrist Name: (Please check the conditions below that you are currently experiencing and/or have previously experienced) Constitutional Symptoms: Fevers Chills Sweats Weight Loss None Apply Head, Eyes, Ears, Nose and Throat: Wearing Of: Contacts Dentures Eyeglasses None Apply Have/Have Had: Double Vision Cataracts ENTM: Difficult To Swallow Neck Pain Sore Throat Nose Bleeds Dizziness Ringing In Ears None Apply Cardiovascular: Chest Pain Heart Attack Congestive Heart Failure Heart Murmur Palpitations Swelling In Legs/Ankles Leg Pain W/ Exercise Cardiovascular Surgery None Apply Hematological/Lymphatic (Blood) : Bleeding Abnormalities Anemia Lump In Groin Or Armpit Lymphoma Swollen Glands None Apply Respiratory: Shortness Of Breath Emphysema Cough Bronchitis Difficulty Breathing Wheezing Asthma Previous Pulmonary Disease TB (Tuberculosis) Exposure or Treatment Pneumonia None Apply Gastrointestinal: Nausea Vomiting Diarrhea Constipation Stomach Ulcers Decrease In Appetite Blood In Stool Hepatitis Acid Reflux None Apply Endocrine: Often Thirsty Often Urinating Kidney Disease Pancreatitis Diabetes Mellitus Prostate Problems Thyroid Disorder None Apply Musculoskeletal: Tendonitis Bursitis Broken Bones Arthralgia Weakness of Limbs Feeling Weak Joint Pain None Apply Nervous System: Migraines Seizures Stroke Nervous Disorder Ataxia (Loss of Balance) Aphasia (Loss of Speech) Confusion Fainting Neuropathy (Loss Of Sensation) Speech Difficulties None Apply Integumentary: Rash Skin Ulcers Lesions Cracking Of Skin Sensitivity to Sun Change In Skin Color Growth on Skin Recurrent Infections Eczema Keloid Hair Loss None Apply Psychiatric: Nervousness Tension Depression Anxiety None Apply To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. Patient/Guardian Signature: Date:

4 Brazos Valley Foot Care, PA ASSIGNMENT OF BENEFITS AND FINANCIAL AGREEMENT My signature at the bottom of this form authorizes payment for services rendered to myself or my dependant to be made directly to Brazos Valley Foot Care, PA. This authorization is valid until I notify Brazos Valley Foot Care, PA in writing that it is revoked. I understand that I am responsible for giving Brazos Valley Foot Care, PA the correct insurance information at the time services are rendered. Brazos Valley Foot Care, PA agrees to bill your primary insurance carrier. If you have more than one insurance we will bill your secondary insurance one time for each visit as a courtesy. If payment is not received from your secondary within 45 days the balance becomes your responsibility. All insurance information must be provided to our office at the time of service. I understand that I am responsible for obtaining the proper referral and may be held responsible for charges not covered by my insurance due to my failure to obtain the required referral. I agree to pay for non-covered services under my insurance plan (services for which your policy excludes). I understand that Brazos Valley Foot Care, PA is not responsible for knowing if the group/physician is a participating provider with my insurance carrier. We at Brazos Valley Foot Care, PA expect that all accounts should be paid by the receipt of the first two statements. If your account has not been settled either by payment in full or by contacting our billing department to set up a payment plan, we will charge a $10 re-billing fee for each additional statement that we mail. If you have made arrangements with our office, we will not charge the re-billing fee for statements sent. Your account will be turned over to collection if you do not fulfill the terms of your financial arrangements. I understand that there is a fee $25 fee for all returned checks. I understand that if I do not call to cancel my appointment within 24 hours there will be a $25 fee applied to my account. By signing this form, Brazos Valley Foot Care, PA is authorized to file an appeal on your behalf if your insurance company denies your claim(s). I understand that I am responsible for all balances not paid by my insurance carrier, including deductibles, co-pay, and co-insurance and out of network penalties. I further understand that if this balance is turned over to an outside collection agency that I shall be liable for all costs of collection and any attorney fees and/or court costs incurred by this office. Patient or Patients Guardian or Legal Representative Signature Date Name of Patient or Guardian or Legal Representative Relationship to patient

5 ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I was provided a copy of the Notice of Privacy Practices. I have read and/or was given the opportunity to read if I so chose and understood the Notice. ** Patient Name (Please Print) Date Parent or Authorized Representative (if applicable) Signature ** Notice of Privacy Practice Packets are available at the front window

6 Name Date WELCOME TO OUR OFFICE THANK YOU FOR CHOOSING US FOR YOUR FOOT CARE! How did you find out about us? Please mark the block that applies and tell us who referred you! Your Insurance? The Phone Book - Which one? Verizon AreaWide Names&Numbers Television? Print Media? (newspaper, town magazines, etc.?) Internet? One of our patients their name? A Friend What is their name? A Relative What is their name? How are they related? Your Primary Care Physician Physician s Name? Another Physician - Name? Other Health Care Service Name? Other?