Robert E. Sussman, D.P.M. Evan Adler, D.P.M 2260 Highway 33 Neptune, NJ 07753 (732)-776-7260 Patient Information Sheet (Please Print) Name: Last First MI Address: Street Address City/State Zip Code Home Phone: Cell Phone: DOB: / / Age: Sex: Male Female Social Security Number: - - Ethnicity: Primary Language: Marital Status: Single Married Widowed Divorced Occupation: Employer: Emergency Contact Name: Relationship: Emergency Contact Number: Primary Physician: Address: Date last seen: Phone: May we contact your Physician about your heath? Yes NO Pharmacy Name: Phone: How did you hear about our office? Insurance Information Company/ Program Name Insured SS# Group Policy 1. 2. 3.. PERSON RESPONSIBLE FOR BILL OTHER THAN ABOVE Name Date of Birth Social Security Insured s Address if Different from above Relationship Insured s Telephone Number Insured s Employer Name
Present Foot Condition Describe your foot problem: (Left) (Right) or (Both) How long has it been bothering you? What makes it better or worse? ( Include prior medical treatments, medications, physical therapy, injections, ect.) Have you had any past problems with your feet or ankles? Include Employment: Height: Weight: Shoe Size: General Health Information Medical History ( Please Circle all that apply to you): High blood pressure Diabetes Insulin or Non-insulin Liver Disease Heart Disease/ attacks COPD Kidney Disease Skin Conditions Describe: Peripheral Vascular Asthma Stomach Ulcers Gastric Reflux Disease Congestive Heart Failure Cancer Thyroid Disease History of leg or foot Ulcers Psoriasis Rheumatoid Arthritis Varicose veins Multiple Sclerosis Bleeding Disorder Osteoarthritis Lyme Disease Hepatitis Blood clot or DVT HIV Inflammatory Bowel Neuropathy Disease Please list any medical conditions you may not have mentioned above: Allergies Gout Please circle all allergies that apply to you: Penicillin Sulfa Latex Ibuprofen (Advil, Motrin, Aspirin) Codeine Iodine/ Betadine Local Anesthetics (Novocaine, Lidocaine) Surgical Tape Please list any other allergies that are not included:
Medications Please list any medications that you are currently taking: Past Surgical History Please list any surgical procedures that you may have had in the past: Family History Mark all that apply to members of your family: Mother Father Brother Sister Grandparents Bunions Flatfeet Hammertoes Heart Disease Diabetes Stroke Cancer Kidney Disease Lung Disease Rheumatoid Arthritis Bleeding Disorder Hepatitis Mother Living Deceased Cause of Death Father Living Deceased Cause of Death Brother Living Deceased Cause of Death Sister Living Deceased Cause of Death Please list any medical diseases that a member of your family may have that are not mentioned above:
Social History Do you drink alcohol or beer? None Light Usage Moderate Heavy (1-2/week) (1-2/day) (2 or more/day) Do you smoke? yes no packs per day How long have you been a smoker? Did you previously smoke? no yes Street Drug use? yes no; Type of drug? Please check one: Type of Employment: sits at job stands at job stands and walks at job retired Signature: Date:
ACKNOWLEDGEMENT OF INSURANCE AND PRIVACY ACT HIPPA I have been given the Notice of Privacy Practices (HIPPA) form. YES NO I hereby authorize payments directly to Robert E. Sussman, D.P.M & Evan Adler, D.P.M. for surgical and/or medical benefits. YES NO Please be advised that it is the patient s responsibility to familiarize themselves with the benefits and restrictions of their insurance company. The patient assumes responsibility for any co-payments, co-insurance, or referrals required by their insurance company. I have read and do understand the above statement. Signature: Date: I HEREBY AUTHORIZE RELEASE OF INFORMATION FOR INSURANCE CLAIMS PURPOSES. I understand all of the above and hereby state that the information is correct to the best of my knowledge. Signature: Date:
PATIENT DESIGNATION OF PARTIES FOR RELEASE OF INFORMATION As this office is in compliance with HIPPA requirements, we need you to designate any person or persons who you wish to allow access to your medical information in this office. I hereby designate the following people to be allowed to access to my medical information, I authorize Dr. Sussman, Dr. Adler and office staff to release information on my condition to these parties. Please Print Clearly 1. Relationship 2. Relationship 3. Relationship (Signature of Patient or Authorized Representative) Date I hereby authorize Dr. Sussman, Dr. Adler & office staff to leave voice mail messages. Confirming my appointments Regarding test/lab results within normal limits Home Phone Yes No Yes No Cell Phone Yes No Yes No Business Phone Yes No Yes No (Signature of Patient or Authorized Representative) Date
Robert E. Sussman, D.P.M. Evan Adler, D.P.M 2260 Highway 33 Neptune, NJ 07753 (732)-776-7260 To Our Patients, Please note: There are over 1,000 insurance plans in America. Most insurance carriers differ on a per patient basis. Therefore, it is impossible for our office to know the covered benefits of your insurance plan. Please be sure to contact your current insurance carrier to verify our participation with your insurance carrier and to verify coverage information if you are uncertain what your plan covers. It is the responsibility of the patient to know/ understand eligibility, policies, procedures, services, and benefits of their insurance. o Referral Requirements ( They must be obtained and presents prior to any services being rendered) o Co-Insurances o Co-Payments o Deductibles o Covered hospital services (admissions, diagnostic testing, labs, x-rays, EKG s, etc.) o Prior authorization procedures o Correct insurance subscriber information and current claims address Our office recommends the following: When contacting your insurance carrier regarding coverage questions or concerns, it would be wise to document the name of the person you are speaking to, the date and time you called. Remember to keep this information for future reference. It is important for you to understand that the physician must document and code according to what services were provided to you, regardless of your coverage. Please be mindful that the insurance carriers determine what services are covered under your policy, not the physicians. Please keep the office informed of any changes in your address, telephone number, or insurance information. We will be happy to submit any insurance claims to your primary or secondary insurance carriers, but we must have the most recent and accurate information to do so. Your insurance cards must be presents at each visit. Thank you in advance for your cooperation. Signature: Date:
Robert E. Sussman, D.P.M. Evan Adler, D.P.M 2260 Highway 33 Neptune, NJ 07753 (732)-776-7260 Cultural Competency: The State of New Jersey mandates that every physician documents any barriers to care including cultural and linguistic needs in the medical record. Factors affecting care are visual or auditory factors which may impede your ability to comprehend medical discussion and language, cultural and/or religious customs, which may impact the provider s ability to provide medical care. Addressing these needs will improve patient satisfaction and also decrease health care disparities. Do you have any Impairment- (i.e. Visual, hearing, speech, learning, physical and language/cultural barrier) What language do you speak, read or write? Do you have any religious or cultural customs that the doctor should know about? Yes No If yes, please describe. Advance Directives: For all patients 18 years and older: Advanced directives are a federal and state mandated Self-Determination Act enacted in 1990. This allows you to provide specific instruction and direction regarding your own medical care wishes if you became incapacitated. The patient-physician relationship provides a direct opportunity for you to discuss these types of decisions. Do you have a Living Will or Advance Directive? Yes No Would you like to know more about a living will? Yes No Social History: For all patients 12 years and older: Do you smoke? Yes No If yes, how much do you smoke per day? Do you use street drugs? Yes No If yes, type and how often? Do you drink alcoholic beverages? Yes No If yes, type and how often? Patient s Name: Signature: Date: