PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
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1 PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL PHONE EMPLOYED BY EMPLOYERS ADDRESS BUSINESS PHONE INSURANCE INFORMATION PRIMARY INSURANCE COMPANY ID # GROUP# POLICY HOLDER EMPLOYER POLICY HOLDER NAME S.S.# D.O.B. RELATION TO PATIENT HOME ADDRESS CITY STATE ZIP HOME PHONE SECONDARY INSURANCE COMPANY ID # GROUP# POLICY HOLDER EMPLOYER POLICY HOLDER NAME S.S.# D.O.B. RELATION TO PATIENT HOME ADDRESS CITY STATE ZIP HOME PHONE RACE: American Indian or Alaska Native Asian Black or African American White Other Declined Hawaiian or Pacific Islander ETHNICITY: Hispanic or Latino Not Hispanic or Latino Unknown Declined LANGUAGE: Arabic Chinese English French Japanese Spanish Vietnamese HOW DID YOU FIND OUT ABOUT OUR OFFICE? WERE YOU REFERRED BY A PHYSICIAN S OFFICE? YES NO WERE YOU REFERRED BY A PATIENT OF OURS? YES NO IF YES, NAME OF PATIENT OR PHYSICIAN REFERRING IT IS OUR POLICY TO INFORM EACH PATIENT S PRIMARY CARE PHYSICIAN CONCERNING THE TREATMENT GIVEN IN IN OUR OFFICE. PRIMARY CARE PHYSICIAN ADDRESS I GIVE PERMISSION TO PODIATRIC ASSOCIATES OF NORTHWEST OHIO, INC. TO EXAMINE AND TREAT MY FEET AND ANKLES AND TO SUBMIT MY INCURRED CHARGES TO MY INSURANCE COMPANY SIGNATURE DATE If you need help filling out this form, we will be happy to help. Just ask a member of our staff for assistance. OVER
2 AUTHORIZATION TO RELEASE PERSONAL HEALTH INFORMATION TO FAMILY AND FRIENDS In order to comply with patient privacy regulations, including the federal Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) regulations on patient privacy and confidentiality, 45 C.F.R. Parts 160 and 164, I hereby authorize the use or disclosure of personal health information about me as described below. 1. I authorize the disclosure of my clinical health information by Podiatric Associates for the duration of my treatment. 2. Podiatric Associates may release my personal health information that is described above to the following person(s). Name Relationship Home Phone Cell Phone I understand that I may revoke this authorization in writing at any time, except for the information that has already been disclosed by Podiatric Associates in reliance on this authorization, by sending a written revocation to Podiatric Associates, 609 Ford Street, Maumee, Ohio, Patient Name Signature of Patient Date Name of Personal Representative (if applicable) Witness Signature Date
3 PODIATRIC ASSOCIATES OF NW OHIO, INC. PRINT NAME DATE MEDICAL INFORMATION THIS INFORMATION IS IMPORTANT FOR OUR RECORDS AND YOUR HEALTH DESCRIBE YOUR FOOT/ANKLE PROBLEM ) How long has it been bothering you? Days Weeks Months Years What treatment have you tried? Any past problems of your feet and ankles? Shoe Size Current Weight Current Height CURRENT MEDICATIONS: (Including supplements) Name of your Pharmacy Phone# ALLERGIES: 1. Antibiotics (Penicillin, Sulfa drugs, etc.) 2. Other Medicines 3. Any problem with local anesthetics (Novocain, Lidocaine)? Yes No 4. Latex Betadine (Iodine) Metals (Gold, etc.) Medical Tape 5. Have you had problems taking aspirin or Ibuprofen (Advil, Motrin)? Yes No LIST ANY SERIOUS ILLNESS WHICH YOU HAVE HAD LIST ALL SURGERIES WHICH YOU HAVE HAD (OVER)
4 REVIEW OF SYSTEMS 1. CONSTITUTIONAL SYMPTOMS Good general health lately... Yes q No q Recent weight change... Yes q No q Fever... Yes q No q Fatigue... Yes q No q 2. EYES Eye disease or injury... Yes q No q Wear glasses/contact lens... Yes q No q Blurred or double vision... Yes q No q Glaucoma... Yes q No q 3. EARS/NOSE/MOUTH/THROAT Hearing loss or ringing... Yes q No q Earaches or drainage... Yes q No q Chronic sinus problem or rhinitis... Yes q No q Nose bleeds... Yes q No q Mouth sores... Yes q No q Bleeding gums... Yes q No q Sore throat or voice change... Yes q No q Swollen glands in neck... Yes q No q 4. CARDIOVASCULAR Heart trouble... Yes q No q Chest pain or angina pectoris... Yes q No q Palpitation... Yes q No q Shortness of breath with walking or lying flat... Yes q No q Swelling of feet, ankles or hands... Yes q No q 5. RESPIRATORY Chronic or frequent cough... Yes q No q Spitting up blood... Yes q No q Shortness of breath... Yes q No q Asthma or wheezing... Yes q No q 6. GASTROINTESTINAL Loss of appetite... Yes q No q Change in bowel movements... Yes q No q Nausea or vomiting... Yes q No q Frequent diarrhea... Yes q No q Painful bowel movement or constipation Yes q No q Rectal bleeding or blood in stool... Yes q No q Abdominal pain or heartburn... Yes q No q Peptic ulcer (stomach or duodenal)... Yes q No q 7. PSYCHIATRIC Memory loss or confusion... Yes q No q Nervousness... Yes q No q Depression... Yes q No q Insomnia... Yes q No q 8. GENITOURINARY Frequent urination... Yes q No q Burning or painful urination... Yes q No q Blood in urine... Yes q No q Incontinence or dribbling... Yes q No q Kidney stones... Yes q No q 9. MUSCULOSKELETAL Joint pain... Yes q No q Joint stiffness or swelling... Yes q No q Weakness of muscles or joints... Yes q No q Muscle pain or cramps... Yes q No q Back pain... Yes q No q Cold extremities... Yes q No q Difficulty in walking... Yes q No q 10. INTEGUMENTARY (Skin, Breast) Rash or itching... Yes q No q Change in skin color... Yes q No q Change in hair or nails... Yes q No q Varicose veins... Yes q No q 11. NEUROLOGICAL Frequent or recurring headaches... Yes q No q Light headed or dizzy... Yes q No q Convulsions or seizures... Yes q No q Numbness or tingling sensations... Yes q No q Tremors... Yes q No q Paralysis... Yes q No q Stroke... Yes q No q Head injury... Yes q No q 12. ENDOCRINE Glandular or hormone problem... Yes q No q Thyroid disease... Yes q No q Diabetes... Yes q No q Excessive thirst or urination... Yes q No q Heat or cold intolerance... Yes q No q Skin becoming drier... Yes q No q 13. HEMATOLOGIC/LYMPHATIC Slow to heal after cuts... Yes q No q Bleeding or bruising tendency... Yes q No q Anemia... Yes q No q Phlebitis... Yes q No q DVT/Blood Clots... Yes q No q Past transfusion... Yes q No q Enlarged glands... Yes q No q 14. OTHER
5 PODIATRIC ASSOCIATES OF NW OHIO, INC. PRINT NAME DATE FAMILY HISTORY: HAS ANY BLOOD RELATIVE HAD: IF YES PLEASE INDICATE WHO: 1. Tuberculosis... Yes q No q 2. Cancer... Yes q No q 3. High blood pressure... Yes q No q 4. Heart trouble... Yes q No q 5. Diabetes... Yes q No q 6. Birth abnormalities... Yes q No q 7. Arthritis... Yes q No q 8. Stroke... Yes q No q 9. Foot problems... Yes q No q 10. Mother living... Yes q No q Cause of death Age of death 11. Father living... Yes q No q Cause of death Age of death 12. Brother living #... Yes q No q Cause of death Age of death 13. Sister living #... Yes q No q Cause of death Age of death PATIENT MEDICAL HISTORY: 1. Stroke... Yes q No q 2. Heart Attack... Yes q No q 3. Heart Disease... Yes q No q 4. High Blood Pressure... Yes q No q 5. Heart Murmur... Yes q No q 6. Cardiac Arythmia... Yes q No q 7. Cholesterol Disease... Yes q No q 8. Circulation Disease... Yes q No q 9. Diabetes... Yes q No q 10. Kidney Disease... Yes q No q 11. COPD / Emphysema... Yes q No q 12. Asthma... Yes q No q 13. Ulcer / GERD... Yes q No q 14. Bleeding Disorder... Yes q No q 15. Anemia... Yes q No q 16. Hepatitis (circle one) A B C... Yes q No q 17. HIV / AIDS... Yes q No q 18. Osteoporosis... Yes q No q 19. Fibromyalgia... Yes q No q 20. Arthritis... Yes q No q Type 21. Gout... Yes q No q 22. Mental Illness... Yes q No q 23. Depression... Yes q No q 24. Thyroid Disease... Yes q No q 25. Pregnant... Yes q No q 26. Cancer... Yes q No q Type 27. Frequent Infections... Yes q No q 28. Do you have any artifical joints?... Yes q No q Type: Hip q Knee q Other 29. Do you smoke?... Yes q No q #Packs per day How long been smoking? 30. Previously smoked?... Yes q No q #Packs per day Date quit smoking? 31. Recreation drugs?... Yes q No q 32. Drink alcohol or beer?... Yes q No q light (1-2 per week) q moderate (1-2 per day) q heavy (more than 2 daily) q 33. EMPLOYMENT (Check those that apply): Sit at job q Stands and walks at job q Retired q Stand at job q Other q 34. EXERCISE ROUTINE... Yes q No q Type Frequency (OVER)
6 Podiatric Associates of Northwest Ohio, Inc. Patient Financial Policy Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor. As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office. Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check. Failure to pay your co-pay at the time of service will result in a $5.00 charge. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. We have made prior arrangements with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible at the time of service. If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service. 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 inform the office of all-insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied. For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility. There are certain elective surgical procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery. Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office. There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee. CHARGES FOR MISSED APPOINTMENTS: Office visit $ Surgery/Procedure $50.00**this is not covered by insurance. Completion of Forms- There is a fee of $20.00 for form completion. This is due from the patient prior to having form completed. Copy of Medical Records or X-ray- A fee of $10.00 will be charged for a copy of the x-ray. The fee for medical records follows the Ohio law. Signature of Patient/Responsible Party: Printed Name of Patient/Responsible Party: Date: Patient initials to indicate copy received. Revised March 2015
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