Welcome to Doctors Foot Center

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Dear Patient, Welcome to Doctors Foot Center We are glad you chose Doctors Foot Center for your podiatry needs. Please find the enclosed paperwork required for new patients at our office. Please complete all pages (front and back) and sign where noted and arrive 15 minutes prior to appointment time. As our patient, you are responsible for all authorizations and or referrals needed to seek treatment in this office. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be not covered or you do not have an authorization, you will be responsible for the complete charge. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. You must notify our office of all insurance changes and authorization or referral requirements. In the event that our office is not informed, you will be responsible for any charges denied. Unless other arrangements have been made in advance, your co-pay or co-insurance is due on the day of your visit. We accept cash, personal check, Visa and MasterCard. There is a $25.00 service fee on all returned checks and past due accounts are subject to collection proceedings. Having all required items and paperwork completed at the time of your appointment helps with the time it takes to process you as a new patient. If you arrive without all items, you may be required to reschedule your appointment. Because of our busy schedule and high demand for appointments, any new patient missed without calling our office 24 hours prior to appointment to cancel, you will be charged $50.00. Once you are an established patient the charge will be $25.00. If you have any questions, please feel free to contact our office at 304-363-3338. Please bring: Completed Paperwork Insurance card(s) Photo ID Current List of All Medications X-ray Films or X-ray/MRI Disc Test results if any We look forward to seeing you at your upcoming visit. Sincerely, Doctors Foot Center & Staff

Doctors Foot Center Welcome to our office Please answer the following questions completely and sign where noted. Patient Information What is the problem with your feet? Patient Name: Date: / / Social Security #: - - Birthdate: / / Sex: M/F Home Phone# ( ) - Cell Phone # ( ) - Mailing Address: _ City: State: Zip Code: Work # ( ) - Occupation: Emergency Contact: Phone# ( ) - Primary Care Physician: Referring Physician: Pharmacy: Which Location? Health Insurance: 1 st 2 nd Responsible Party Information (if patient is a minor) Name: Relationship: Birthdate: / / Social Security # - - Mailing Address: City: State: Zip Code: Home Phone # ( ) - Cell Phone # ( ) - Work # ( ) - Occupation:

Consent for Treatment and Financial Arrangements I hereby consent to and authorize any examination and administration of all treatments that may be considered advisable or necessary in the judgment of the physician. I understand that charges will be made for the services of Doctors Foot Center and for X-ray, laboratory, drugs, and other services. I, and any representative signing for me, agree to pay for charges when billed. I authorize direct payment to Doctors Foot Center of any insurance or health plan benefits applicable to said charges. I authorize Doctors Foot Center to release any medical or other information about me to my insurance company or health plan, attending, family, referral and/or company physician. If my account is referred to an attorney/collection agency, I agree to pay attorney s fees and cost of collection. I authorize the use of this signature on all insurance submissions. I understand that it is my responsibility to inform the doctor s office if there is a change in my health insurance information or demographics. Signature of Patient or Responsible Party: Date:

Medications **Please list all prescription medications, over-the-counter medications, vitamins & supplements. **If you have a list, please give it to the receptionist. You do NOT need to write the medications on sheet. **Are you taking any Blood Thinner Medications? Yes/No** Medication Name Dosage How Often Medication Allergies NO KNOWN DRUG ALLERGIES Medication/Reaction Penicillin Morphine Codeine Demerol Novocain Aspirin Tylenol Sulfa Drugs Adhesive Tape Iodine/Betadine Latex Motrin/Advil Any Other Medication Allergies Not Listed

Medical History Do you have or have been treated for: Alzheimer s Ankle Sprain Anxiety Arch Pain Asthma Athlete s Foot Back Problems Bleeding Disorders Broken Ankle Broken Foot Bones Bunions Burning in Feet Cancer Chemotherapy Corns/Calluses Edema/Swelling Chronic Pain Congestive Heart Failure COPD Cramps in Legs/Feet Depression Diabetes (Insulin/Oral/Diet) Dialysis Difficulty Swallowing DVT (Deep Vein Thrombosis) Emphysema Eyesight Difficulties/Blind Fibromyalgia Flatfeet Fungal Nails GERD GI Bleed Gout Hammer Toes Hearing Difficulties/Deaf Heart Attack Heart Disease Heart Stents Heart Valve Replacement Heel Pain Hepatitis A/B/C High Arch Feet High Blood Pressure High Cholesterol HIV Ingrown Nails Joint Implants Kidney Disease Kidney Stones Knee Pain Liver Disease Neuroma Numbness in Feet Osteoarthritis Osteoporosis Pacemaker Peripheral Neuropathy Peripheral Vascular Disease Phlebitis Poor Circulation Pregnant Psoriasis Psychiatric Disorder Rheumatic Fever Rheumatoid Arthritis Seizures Slow or Delayed Healing Stomach Ulcer Stroke Thyroid Disease Tuberculosis Ulcers Legs/Feet Varicose Veins Vascular Grafts Warts NONE Family History Mother/Father/Siblings Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease NONE Surgical History NONE Angioplasty Appendectomy Back Breast Biopsy L/R C-section Carotid Artery Cataract L/R D and C Gall Bladder Heart By-Pass Heart Stents Hip Replacement L/R Hysterectomy Knee Replacement L/R Leg Artery Bypass/Stent L/R Open Heart Pacemaker Tonsillectomy Venous Ligation L/R Other Surgical Complications: Infections Slow to Heal Blood Clot Excessive Bleeding Problems w/ Anesthesia Social History Smoke Yes/No ½ pack day/ yrs 1 pack day/ yrs 2 pack day/ yrs Other Date Quit Alcohol Yes/No Social Moderately Other Date Quit

Doctors Foot Center Dr. Rusty Cain Acknowledgment of Receipt of Notice of Privacy Practices I acknowledge that I was provided a copy of the Notice of Privacy Practices. Patient Name (please print) Parent/Guardian (if minor) Authorization To Release Information I authorize the following individuals to have access to my Protected Health Information. Please list names: I give permission for Doctors Foot Center to leave messages at the numbers provided in patient information. YES NO Signature: Date: / /

Doctors Foot Center Financial Policy Welcome to Doctors Foot Center. It is our goal to provide you with high quality care not only medically but in all other aspects as well. Should you receive a bill from us that you do not understand or feel that you may have received in error, please call our billing department promptly. Insurance: We participate in most insurance plans. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. We must obtain a copy of your driver s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Medicare: We are a participating Medicare provider. Medicare, as well as your secondary insurance (if any), will be billed for you. However, that does not mean that all services are covered. Patients are responsible for paying their annual deductible if it has not yet been met. You are also responsible for any co-payments which are usually 20% of the allowed amount for an item or service. Secondary Insurance: Your medical claim will be forwarded to your secondary insurance (if any) after payment and/or explanation of benefits (EOB) is received from your primary insurance company. Co-payments and Deductibles: All co-payments and deductible must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. Self Pay: Payment in full is due at time of service if you do not have health insurance; unless other arrangements have been made prior to each visit. Non-Covered Services: Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for payment of these services. Referrals/Authorizations: We are required to follow guidelines of your managed care plan which mandates us that when you visit a specialist such as ours, you must have a referral from your primary care physician prior to seeking specialty care. Therefore, you are financially responsible for the services received, unless your referral is presented at the time of this visit. If you fail to get a referral from primary care physician, you will be financially responsible for all services received due in full upon completion of the visit. Full credit will be given if a referral is presented to our office within 48 hours of this visit. You will also be given the option to reschedule your appointment. Claim Submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company. Patient Billing: You will be sent up to 3 notices for your financial responsibility (co-insurance, deductible) after payment and/or explanation of benefits (EOB) is received from your insurance company/companies. After the 3 rd and last notice, your account may be forwarded to collections. Please let the billing office know if you have any difficulties resolving your bill. Payment arrangements can be made on a case by case basis. We accept the following payment methods: Cash, Check, Visa or MasterCard. An additional $25.00 will be added to your statement if the check is returned for insufficient funds. In the event that your insurance company should happen to send payment to you, the patient, we expect that you would forward it to our office to be applied to your balance. I have read the above policy regarding my Financial Responsibility to Doctors Foot Center for medical services provided. I agree to pay Doctors Foot Center any balance unpaid by my insurance carrier for myself or the below named person. Signature of Responsible Party: Date: / /

Doctors Foot Center Rusty L. Cain, DPM Missed Appointment Policy All patients are required to sign. Due to high demand of patients needing appointments, there will be a $25 charge for failure to cancel 24 hours prior to your scheduled appointment. Please call our office at 304-363-3338 to cancel or reschedule your appointment so that other patients get the opportunity to come in sooner if needed. Patient Signature: Parent or Guardian if minor: Date: Witness: As of 10/1/2012.

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