Welcome To Pacific Foot & Ankle Clinic LLC

Transcription

1 Welcome To Pacific Foot & Ankle Clinic LLC Thank you for selecting our office for your foot and ankle health care needs. We have prepared this packet of information and patient forms in order to help make your visit a convenient and pleasant experience. Prior to your appointment, please contact your insurance company to clarify your coverage requirements. URGENT INFORMATION ABOUT REFERRALS: You cannot assume that your referral has been approved unless you have received written confirmation from your insurance company. If you are not sure your referral has been approved, please contact your insurance company prior to your appointment. If Pacific Foot & Ankle Clinic LLC does not have a paper copy of the referral in the office you will be financially responsible for the appointment, unless other arrangements are made at the time of service. When you come for your appointment, please bring the following: Written Referral (if required by your insurance company) Completed Registration form Completed History Form Medical Insurance Card Previous X-rays and medical records, if applicable Shoes (bring a sample, only need one shoe per pair, of the more common shoes you wear-including athletic and walking shoes.) Note as you will be receiving advice on the proper shoes for your feet, we recommend you do not purchase any new shoes prior to your visit. Please be prepared to pay for the following at the time of your visit. Co-payment (if applicable) Deductable (if not fully paid for this year) If no-insurance, the full cost of visit. Our entire staff is here to help you in whatever matter we can. We look forward to serving you in the near future. Your Scheduled appointment is at AM or PM. As a courtesy to other patients who are waiting to get in, please call at least 24 hours in advance if you must cancel your appointment. We reserve the right to charge for missed appointments.

2 HIPPA Acknowledgment and Consent By signing below, I agree that I have reviewed and understand the information above. FEDERAL LAW REQUIRES THAT YOU HAVE ACCESS TO THIS INFORMATION The information that we obtain directly from you as a patient is considered "protected health information." This means that anything you tell us or give to us in writing is "protected." According to the Health Insurance Portability and Accountability Act of the federal government, that means we have to have your actual consent to use the information. It also means that we can only use the information for medical treatment, to get payment, or other healthcare operations. For a more complete description of the laws and our policies, you should ask the receptionist for our Notice of Privacy Practices. You have the right to review the NOTICE anytime you come into this office. I understand that my health information may include information both created and received by the practice, may be In the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar type of health-related information. I understand and agree that this practice may use and disclose my health information in order to: 1.) Make decision about and plan for my care and treatment; 2.) Refer to, consult with, coordinate among, and manage, along with other health care providers, for my care and treatment. 3.) Perform various office, administrative, and business functions that support my physician's efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care; 4.) Determine my eligibility for health plan or insurance coverage, and submit bills, claims, and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and I also understand that I have the right to receive and review a written description of how this practice will handle health information about me. This written description is known as a NOTICE OF PRIVACY PRACTICE and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of this practice, and my rights regarding my health information. I understand that the NOTICE OF PRIVACY PRACTICES may be revised from time to time, and that I am entitled to obtain a copy of any revised NOTICE OF PRIVACY PRACTICES. I also understand that a copy or a summary of the most current version of this NOTICE in effect will be posted in the waiting/reception areas. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the NOTICE, and I understand that this practice is not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above. Patient's Signature Date Legal Guardian/Date Power of Attorney Date

3 Credit, Referral and Cancellation Policy According to your insurance plan rules, at the time of each visit to our office, you are required to: Bring your insurance card for us to copy. Pay the contracted copayment or any annual deductible amount not yet paid. Present to our office a signed referral form from your referring doctor or from your insurance plan. It is your responsibility to obtain one before being evaluated and/or treated. We will bill your primary insurance company for you, provided that we have all of the necessary information, including insurance name, billing address, patient identification number and/or group number. We allow 45 days for insurance processing. If your insurance company has not responded within that time period, a payment is expected from you. An insurance policy is a contract between you and your insurance company. Statements are mailed out monthly. Payment in full is due upon receipt of the statement unless payment arrangements have been made with our office. A regular monthly payment plan can be arranged if you are unable to pay the entire balance at once. Your cooperation is requested to avoid any collection procedures. Accounts over 30 days old will be subject to a rebilling fee of $10.00 per month at our discretion. If we do not receive payment from you, your account will be turned over to a collection agency. You will be charged for any collection and/or attorney s fees. Final responsibility for your payment of your account is yours. ***Cancellations, if you cancel within the same day you will be subject to a $25.00 cancellation charge. If you cancel outside the same day there will be no charge. A missed appointment will also be subject to a $25.00 charge. If you have a change to your mailing address, phone number or insurance, please notify our office as soon as possible. Your signature on this page certifies that you have read and understand the policy as stated above. It authorizes the release of medical information necessary to process this claim for services. It authorizes payment of medical benefits to the above named Doctor/Offices for services described on itemized statements and/or insurance claim forms Patient s Signature: Date: Responsible Party: Date: Witness: Date:

4 1. Patient Information New Patient Registration Last Name First Name Middle Initial Date of Birth Age Marital Status Sex Address City State Zip Code Home Phone Work Phone Cell Phone Referral: Whom may we thank for your referral? Primary Care Physician: (if not the same as above) 2. Insurance Information (Please help us update your insurance information if it has been changed.) I have primary insurance with: I have Secondary Insurance with: No Insurance plan: 3. Emergency Notification Emergency Contact Name: Emergency Contact Phone Number: 4. Patient Signature I hereby authorize Pacific Foot and Ankle Clinic LLC, to release any medical information necessary to Process claims with any insurance companies. I also assign Pacific Foot and Ankle Clinic LLC, all payments to which I am entitled for medical and surgical expenses related to the services reported Herewith. I understand that I am financially responsible for all charges whether covered by insurance or not. Patients Signature Date Responsible Party s signature Date

5 History of deep vein thrombosis post surgery History of Methicillin resistant infections (MRSA)

6 REVIEW OF SYSTEM General [ ] Recent unintentional weight gain [ ] Fever [ ] Fatigue [ ] Headaches [ ] In good health lately Eyes [ ] Eye disease or injury [ ] Double Vision [ ] Blurred Vision [ ] Glaucoma [ ] Eyeglasses and Contact lenses Ear / Nose / [ ] Hearing loss [ ] Ringing in the ears [ ] Ear drainage [ ] Bad Breath & Throat [ ] Sore throat [ ] Swollen glands [ ] Rhinitis [ ] Nose bleeds [ ] Mouth Sores [ ] Bleeding gums [ ] Chronic Sinus issues Heart [ ] Heart trouble [ ] Chest pain [ ] Chest pressure [ ] Skipping heartbeats [ ] Shortness of breath [ ] Sleep with 2 or more pillows [ ] Swelling Lungs [ ] Coughing [ ] Spitting up blood [ ] Asthma [ ] Wheezing GI GU [ ] Appetite change [ ] Change in bowel movement, nausea, or vomiting [ ] Frequent diarrhea [ ] Rectal bleeding [ ] Bloody Stool [ ] Heat burn [ ] Pain with bowel movement [ ] Ulcer disease [ ] Frequent urination [ ] Painful urination [ ] Incontinence [ ] Dribbling [ ] Kidney stones [ ] Impotence [ ] Testicular pain [ ] Dysmenorrheal [ ] Irregular menses [ ] Vaginal discharge Musculoskeletal [ ] Joint pain [ ] Joint stiffness [ ] Joint swelling (especially in the morning) [ ] Muscle or joint weakness [ ] Muscle pain or cramps [ ] Back pain [ ] Difficulty walking [ ] Cold extremities Neurological [ ] Frequent headaches [ ] Light headed [ ] Dizziness [ ] Seizure [ ] Stroke [ ] Numbness or tingling [ ] Tremors [ ] Head injury Psych [ ] Memory loss [ ] Confusion [ ] Nervousness [ ] Depression [ ] Insomnia Skin / Nail [ ] Rash [ ] Itching [ ] Scaling [ ] Change in skin color [ ] Breast pain [ ] Changes in hair or nails [ ] Varicose veins [ ] Breast lump Endocrine [ ] Thyroid Disease [ ] Diabetes Mellitus [ ] Increased thirst or urination [ ] Hot or cold intolerance [ ] change in hat or glove size. Hemo / Lymph [ ] Slow healing [ ] Bleeding disorder [ ] Easy bruising [ ] Phlebitis [ ] Past transfusion [ ] Enlarged glands Height ft in Weight lbs BP P R ROS Reviewed by MA by Physician Date: Reconstructive Foot and Ankle Surgery Specializing in Diabetic Foot Reconstruction