(Please present insurance/government issued photo ID card to receptionist) PATIENT INFORMATION

Transcription

1 CENTRAL ARKANSAS FOOT CARE REGISTRATION FORM (Please present insurance/government issued photo ID card to receptionist) Today s date: Facility: PATIENT INFORMATION Patient s last name: First: Middle: q Mr. q Mrs. q Miss q Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: q Yes q No / / q M q F Street address: Social Security no.: Home phone no.: ( ) Cell phone no: City: State: ZIP Code: ( ) - Occupation: Employer: Employer phone no.: ( ) Chose clinic because/referred to clinic by (please check one box): q Dr. q Insurance Plan q Hospital q Family q Friend q Close to home/work q Yellow Pages q Other INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: Is this person a patient here? q Yes q No / / ( ) Occupation: Employer: Employer address: Employer phone no.: Is this patient covered by insurance? Please indicate primary insurance q Yes q No ( ) q Medicare q Medicaid q BC/BS q Aetna q CIGNA q Windsor q Railroad Medicare q AR Benefit q Tricare Other: Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: Patient s relationship to subscriber: q Self q Spouse q Child q Other / / $ Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: AUTHORIZATION FOR ASSIGNMENT OF BENEFITS TO Joseph M. LaCava DPM, PA X / / Signature Date HIPPA AUTHORIZATION Necessary to process claims X / / Signature Date

2 CENTRAL ARKANSAS FOOT CARE (Please Print) REGISTRATION FORM Today s Date: / / Patient Name: REVIEW OF SYSTEMS If you have had any trouble with the following in the past year, check the problem(s). If you do not have any of the listed problems, please place check in the No Problems line. General: Weight Loss Weight Gain Fatigue Weakness Fever Pain Chills Skin: Rashes Dryness Thick Yellow Nails Ulcerations Changing Color of Skin Eyes, Ears, Nose, Mouth: Dry, red eyes Blurring /changing vision Ringing in ears Hearing Loss Nosebleeds Lungs: Asthma COPD Shortness of Breath Difficulty breathing with Exertion Chronic Cough Heart, Circulation: Chest Pain Irregular Heart Rate Ankle Swelling Low Blood Pressure High Blood Pressure Cold Feet Pain when walking in legs Urinary: Frequency of urination Loss of control of urination Chronic Urination at Night Blood in Urine Gastrointestinal: Nausea, vomiting Diarrhea Changing in bowel habits Stomach Ulceration Acid Reflux, Chronic Indigestion Muscle, Joints, Bones: Bone cancer Joint Pain Chronic Back pain Pain in Legs Joint Swelling Foot Pain Ankle Pain Nervous System: Seizures/Epilepsy Tremors Memory Loss Numbness to hands, feet or legs Paralysis Diabetic Peripheral Neuropathy Peripheral Neuropathy Endocrine, Renal, Blood, Allergies : Diabetes Anemia Easy Bruising Renal Failure Dialysis Allergies to: Latex, Shellfish Iodine on Skin Betadine Lidocaine/Marcaine Psychological: Alzheimer s Bipolar Disorder Schizophrenia Depression Anxiety Illegal Drug Use Alcoholism Patient Name (please print) Patient or Legal Guardian Signature Date 1/2013

3 REGISTRATION FORM Patient s Name: Birth Date: / / ALLERGIES (LIST KNOWN ALLERGIES OR REACTIONS TO DRUGS/MEDICATIONS) Please circle : Penicillin Sulfa Local anesthetic Anti- inflammatory drugs Codeine Tape Latex Nausea from Anesthetic Iodine on skin Other: MEDICATIONS (PLEASE LIST CURRENT MEDICATIONS THAT YOU ARE TAKING: PRESCRIPTION AND OVER THE COUNTER) MEDICATION DOSE MEDICATION DOSE FOOT/ ANKLE PAIN WHERE? How long? Months: Years: WHAT PREVIOUS TREATMENT HAVE YOU HAD ON YOUR FOOT OR ANKLE Surgery Orthotics Oral Medication Cortisone Shots FAMILY PHYSICIAN INFORMATION Medical Doctors Name: Street Address: City / State Zip code Phone# ( ) - Have you ever been put to sleep for surgery? q Yes q No Indicate which of the following YOU have had or have at the present. Check Yes or No to each item. Arthritis/ Rheumatism q Yes q No High Blood Pressure q Yes q No Artificial Joints (hips, knees, etc.) q Yes q No H.I.V. Positive q Yes q No Asthma q Yes q No Kidney Trouble q Yes q No Diabetes q Yes q No Liver Disease q Yes q No Fibromyalgia q Yes q No Motion Sickness q Yes q No Glaucoma q Yes q No Neurological Disorder q Yes q No Heart(Surgery, Disease, Attack) q Yes q No Psychiatric/Psychological Care q Yes q No Heart Murmur q Yes q No Stomach Ulcers/ Reflux /Heart Burn q Yes q No Hepatitis A(infectious), B(serum), or C(infectious) q Yes q No Ulcerations of the foot(diabetic) q Yes q No Indicate which of the following FAMILY MEMBER may have had or has at the present. Circle Mother or Father to each item, If none was present check NONE. Arthritis/ Rheumatism Mother Father High Blood Pressure Mother Father Artificial Joints (hips, knees, etc.) Mother Father H.I.V. Positive Mother Father Asthma Mother Father Kidney Trouble Mother Father Diabetes Mother Father Liver Disease Mother Father Fibromyalgia Mother Father Motion Sickness Mother Father Glaucoma Mother Father Neurological Disorder Mother Father

4 Heart(Surgery, Disease, Attack) Mother Father Psychiatric/Psychological Care Mother Father Heart Murmur Mother Father Stomach Ulcers/ Reflux /Heart Burn Mother Father Hepatitis A(infectious), B(serum), or Mother Father Mother Father Ulcerations of the foot(diabetic) C(infectious) SOCIAL HISTORY Tobacco (including chewing tobacco) q Yes q No Alcohol q Yes q No Smoking Stop treatments q Yes q No Abuse of Narcotics(Pain Medication) q Yes q No PAST SURGICAL HISTORY SURGERY DATE SURGERY DATE DEMOGRAPHICS (FOR GOVERNMENTAL STATISTICAL ANALYSIS) Race American Indian or Alaska Native Asian Native Hawaiian Black or African American White Hispanic Other Pacific Islander Other Race I Decline to Report Preferred Ethnicity: Hispanic Non-Hispanic I Decline to Report Language English Spanish Other PHARMACY/ PRESCRIPTION INFORMATION Preferred Pharmacy: Walgreens Location: Wal-Mart Location: Fred s Location: Kroger Location: National Park Pharmacy Sam s Clubs All care Budget Pharmacy Brookshire Other: check if mail order pharmacy I authorize Central Arkansas Foot Care/ Dr. Joseph M. LaCava DPM to view my external prescription history via the Sure scripts service. I understand that prescription history from multiple other unaffiliated medical provider, insurance companies, and pharmacy benefit managers may be viewable by my provider and staff here, and it may include prescriptions back in time for several years. MY SIGNATURE CERTIFIES THAT I READ AND UNDERSTAND THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS. CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY To Central Arkansas Foot Care Joseph M. LaCava DPM, PA. X / / Signature Date I understand that the above medical information is necessary to provide me with medical care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to as the respective health care provider or agency, who may release such information to you. I will notify the doctor of any changes in my health or medications. X Patient/Guardian Signature Date: / / HISTORY REVIEWED BY: DOCTORS SIGNATURE DATE: / / 1/2013

5 CENTRAL ARKANSAS FOOT CARE FINANCIAL POLICY Thank you for choosing Central Arkansas Foot Care and Dr. Joseph M. LaCava DPM, PA as your health care provider. We are committed to the successful treatment of your condition. Please understand that payment of your bill is considered part of your treatment. Should you have any questions regarding any aspect of your financial status with our office, please feel free to contact our billing department at (501) Your clear understanding of our Financial Policy is important to our professional relationship. WE ARE HAPPY TO BILL YOUR INSURANCE DIRECTLY; HOWEVER, WE MUST HAVE A COPY OF THE INSURANCE CARD(S). IF YOU DO NOT HAVE YOUR INSURANCE CARD WITH YOU, FULL PAYMENT IS DUE AT THE TIME OF THE SERVICE. WE ACCEPT CASH, CHECKS, VISA OR MASTERCARD AND CARE CREDIT CARDS. ALL PATIENTS MUST COMPLETE OUR PATIENT REGISTRATION FORM AND ALL OTHER RELATED FORMS. PLEASE, NOTIFY US IMMEDIATELY OF ANY CHANGES IN YOUR INSURANCE OR COVERAGE. 5 BUSINESS DAYS NOTICE IS REQUIRED FOR COPIES OF MEDICAL RECORDS OR XRAYS AND THERE MAY BE A NOMINAL FEE. YOU WILL BE REQUIRED TO SIGN OUT YOUR XRAYS AND RETURN THEM. Self-Pay We expect payment at time of service unless prior arrangements have been made. Medicare We accept Medicare assignment. As a Medicare patient, you are responsible only for the deductible if you don t have supplemental insurance. A few services and supplies are not covered by Medicare, we will advise you of any non - covered charges prior to the service being provided. HMO ALL CO-PAYMENTS ARE DUE AT THE TIME OF SERVICE. IF YOU DO NOT KNOW YOUR COPAY WE WILL DUE THE BEST WE CAN TO FIND OUT FOR YOU, OR YOU MAY USE OUR PHONE TO CALL YOUR INSURANCE COMPANY TO FIND OUT. We are members of most, but not all plans. You are responsible for verifying that we are providers for your plan. If you are an HMO member, you will not be billed as long as we have the necessary referrals. Please note: You must have the referral at the time of your visit or your plan requires that we ask you to reschedule Financial Agreement I understand that I am financial responsible for all charges not covered by insurance and I guarantee the balance to be paid by my credit card, check or cash. Past due balances may be subject to additional fees. UCR (Usual and Customary Rates) We are committed to provide the best treatment possible for our patients and we charge what is usual and customary for our area. If we do not have a contract with your insurance company, you are responsible for payment in full regardless of any insurance company s arbitrary determinations of UCR rates. I understand that if the office agrees to bill insurance as a courtesy, I must submit information as needed to ensure payment for the services rendered to me. I understand that I am ultimately responsible for payment for all services. If payment is not received from the insurance company or other responsible party in 90 days, I will be billed directly. Name of Patient(please print) Signature of Patient or Responsible Party Date 1/2013

6 Dr. Joseph LaCava DPM and his staff at Central Arkansas Foot Care take pride in excellent and timely foot care. It is for this reason that we schedule individualized appointments for every patient. Due to high demand for foot and ankle care, we often have a delay for non-emergency appointments of at times greater than two weeks. Due to the exceedingly high rate of patients not showing up to appointments without calling to cancel or reschedule at times even after we confirm their personalized appointment we have been forced to enforce a strict no show, no call, policy. Failure to notify the office of rescheduling or cancelling of your appointment within 24 hours will result in a no show fee of $ This fee is not covered by any insurance companies. This fee must be paid prior to rescheduling another appointment. If a patient fails to pay the no show fee or has 3 or more incidences of no show, then the patient will be notified by certified mail of discharge from the practice and no further appointments will be rescheduled. Failure to sign this document will not forego no- show violations and fees. This document will be scanned into your electronic medical record. We do understand that emergency situations happen that do not allow for calling to cancel your appointment. If this is the case, please call within 24 hours and we will reschedule your appointment and waive the fee. Please show compassion for our patients with foot problems and notify the office of your need to cancel or reschedule your appointment. Thank you Dr. Joseph M. LaCava DPM Print Name: Signature: Date: Patient has refused to sign document but was made verbally aware of policy change. Staff Initials: