Patient Registration Form

Do you currently have a living will/advanced directive/Durable Power of Attorney?

Is there anyone beside yourself we can discuss your medical information with?

Is there anyone beside yourself we can discuss your medical information with?

M-Mother F-Father S-Sibling U-Uncle A-Aunt GPA-Grandfather GMA-Grandmother

MEDICATIONS: Include Prescription, over the counter and Vitamins: 

ALLERGIES

CONSENT

I certify that the above information is correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

By signing this acknowledgement of Receipt of Privacy Practices (the “Notice”) I acknowledge and agree that I have received a copy or elected not to receive a copy of this notice of Privacy Practice for review and to keep for my records on the date identified below. 

I understand that the CHOICE PODIATRY CENTER, INC may use and disclose necessary personal information (i.e., name, address, subscribers identification number, podiatry exam information and /or type of products provided) to another in-house employee to permit and perform its administration duties, provide me with podiatry services and products, process my podiatry benefit claims and communicate with me regarding podiatry care services provide by Choice Podiatry Center, Inc (i.e., mailing of exams, reminder information about services/products provided by Choice Podiatry Center, Inc.

I CAN BE ASSURED THAT CHOICE PODIATRY CENTER, INC WILL NOT SELL MY PERSONL INFORMATION OF ANY KIND TO A THIRD PARTY FOR SUCH PARTIES PERSONAL USE. 

Choice Podiatry Center is to submit my podiatry benefit claim to my plan sponsor or health plan to receive reimbursement directly for the podiatry services and products that I received.

Please choose one of the following options:

REGARDING HMO’S, PPO’S and MANAGED CARE PROGRAMS: 

We do not participate in some of these programs, so please check with your insurance company to see if we are providers for your particular plan. It is your responsibility to obtain all referral forms required by your insurance company. Please be aware that if you are seen by our doctor under an out of network insurance plan, you assume liability for the difference in coverage benefits. Some HMO/PPO/Managed Care Primary Care Physicians require all x-rays to be taken at their office so please check with your physician before your appointment. In case your insurance company probably will not pay for items or services provided by our doctors because of: Co‐pay balance, Co‐Ins balance, Deductible balance, Coverage terminated, Member ineligible for Date of Service, Non‐covered charges, Provider out of network, Service is not covered under the patient current benefit plan, Patient cannot be identified as plan member, Maximum Benefit reached, Service after Cancellation, Referral Required, Authorization Required, Care may be covered by another payer, Co‐ordination of Benefits required, Additional information required from Doctor’s office, Member need to update COB, Patient has not met the required eligibility requirements, Plan procedures not followed. The impact of prior payer, Charge exceeds fee schedule, Pre‐existing Conditions, Time limit filling, Entity not eligible for submitted date of service etc, you assume responsibility and liability for the amount owed to our office.

COPAYS:
You will be expected to pay your co-pay at the time of your appointment. If you are unable to pay, you will be required to reschedule your appointment.

REGARDING PATIENTS WITH NO INSURANCE:
Payment is due at the time of service.

REGARDING PATIENTS WITH MEDICARE:
We will file all charges with Medicare and your supplemental insurance if applicable. If you do not have supplemental insurance, you will be billed for the 20% not paid by Medicare, or any deductible that has not been met.

MEDICAID DOES NOT COVER ALL PODIATRY SERVICES FOR INDIVIDUALS. REGARDING WORKMEN’S COMPENSATION/AUTO/LIABILITY:
Our office requires authorization prior to the initial visit. If authorization has not been received by the time of your visit, you will be responsible for the charges associated with your visit. You will be responsible for all fees until the case has been settled. 

MINOR PATIENTS:
Patients under the age of 18 must have a parent and/or guardian accompany them to our office before treatment can be rendered. Arrangements must be made prior to being seen with the parent and/or guardian for any co-pays and payments to be made at the time of treatment. 

LAB:
Our office uses an outside laboratory service. In the event that a lab test is performed, you will receive a separate bill for the lab services.

CUSTOM ORTHOTICS:
If your insurance does not cover orthotics or your deductible has not been met, a payment of half the price of the orthotics will be expected prior to ordering. The remaining half is due at the time your orthotics are dispensed. It is always your responsibility to be sure that your account is settled, regardless of insurance or any other circumstances (such as litigation). The Patient is responsible for costs associated with collecting owed balances including but not limited to, collection agency fees, attorney fees, and court costs. I hereby authorize the release of any information necessary to file a claim with my insurance company and assign benefits to Choice Podiatry Center. 

I acknowledge that I have read the billing policies listed above, agree, and understand my responsibilities as a patient at Choice Podiatry Center. I also understand that if I fail to pay charges, I imply discontinuation of podiatry services. 

We require that you call at least 24 hours in advance. Appointments that are missed will accrue a fee of $75.00 that will be charged to the patient’s account. Thank you in advance for your cooperation. 

AUTHORIZATION OF PATIENT PICTURE, NAME AND AGE TO BE RELEASED FOR THE SOLE PURPOSE OF MARKETING 

give permission to Choice Podiatry Center to use Video and/or pictures in print for marketing and/or educational purposes.

This consent may be withdrawn at any time. Withdrawal of consent must be writing to Choice Podiatry Center physicians or practice manager. 

I acknowledge that I have given my permission and understand that Choice Podiatry Center will use my information regarding any surgical procedure and/or medical treatments for the sole purpose of marketing and/ or educational purposes.