FOOT AND ANKLE OF WEST GEORGIA

Transcription

1 PATIENT INFORMATION : Name: D.O.B. Age: SSN: - - Shoe Size: Weight: Height: Gender: Male Female Marital Status: Single Married Divorced Widow Race: Preferred Language: Ethnicity: _ Street Address: City: State: Zip: Home: - - Cell Phone: - - Work Phone: - - Employer/Occupation: Address: Emergency Contact: Phone Number: - - Relationship: Chief Complaint: _ How long have you had this problem? Attempted Treatments/Effectiveness: REFERRAL SOURCE Whom may we thank for referring you? Doctor: Family/Friend: Hospital: Insurance Provider List/Phone Book Other: TYPE OF INSURANCE (Please provide a copy of your card) Primary: _ Secondary: Other: PRIMARY CARE PHYSICIAN Name: City: Phone: Last Seen: PREFERRED PHARMACY Name: City: Phone: POLICY HOLDER INFORMATION Name: Address: City: State: Zip: Home Phone: SSN: Employer: Work Address: Relation to Patient: 1

2 PATIENT HISTORY Surgery PAST SURGERIES Allergy ALLERGIES Reaction Relationship of family members who have had: Arthritis Cancer (type) Diabetes Foot Problems FAMILY HISTORY Heart Attack High Blood Pressure Stroke _ Other SOCIAL HISTORY Do you smoke? No Yes Packs/Day: _ Years: Did you ever smoke? No Yes Packs/Day: _ Years: If you quit smoking, when? Do you drink alcoholic beverages? None Rarely Daily Quit Do you take recreational drugs? None Rarely Daily Quit Can you take Anti-Inflammatory drugs (Aspirin, Motrin, Aleve, etc)? No Yes Are you pregnant or nursing? No Yes Additional Notes 2

3 REVIEW OF SYSTEMS (Current and/or previously treated for) Acid Reflux ADHD Allergies Alzheimer s Anemia Anxiety Disorder Arthritis Asthma Back Pain Brain Injury Cancer Cerebral Palsy Diabetes Dementia Depression Eczema Foot Fracture Gout Heart Attack Heart Condition Heart Murmur Hepatitis High Blood Pressure High Cholesterol Hip Fracture Hip Fracture Kidney Disease Liver Disease Nerve Disorder Neuropathy Osteoporosis Poor Circulation Stomach Ulcer Stroke Spinal Cord Injury Thyroid Problems Varicose Veins Additional CURRENT MEDICATIONS Name of Drug Dose Frequency 3

4 AUTHORIZATIONS Benefits to Physicians: I hereby authorize the processing of the medical insurance either by electronic or manual method by Foot and Ankle of West Georgia, 2751 Warm Springs Road, Ste A Columbus, GA My signature authorizes payment(s) of all major medical and/or surgical benefits to which I am entitled to the physician. I recognize my financial obligation of any coinsurance, deductible, and non-covered services that may be required. I understand that I am responsible for any portion of my bill not covered by my insurance company. I also understand that if my insurance requires a referral, I will obtain one, or I will be billed in full for my visit. This agreement will remain in effect until revoked by me in writing. A copy of this document is considered as valid as an original. Release of Information: I herby authorize release of information for insurance claim purposes. The information authorized for release may include confidential medical information. I consent to foot and ankle photographs, which may become part of my permanent record and/or sent to other physicians and insurance companies as may be needed for my care. I understand all of the above and hereby stat that the information is correct to the best of my knowledge. _ Signature of Patient and/or Guarantor (Responsible Party) Witness MEDICARE AUTHORIZATION I request that payment of authorized Medicare benefits be made either to me or on my behalf to: Foot and Ankle of West Georgia PC for any services furnished by that physician/supplier. I authorize the holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If the other health insurance is indicated in box 9 of the HCFA-1500 form, or elsewhere on the approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. _ Signature of Patient and/or Guarantor (Responsible Party) Witness 4

5 FINANCIAL POLICY We are committed to providing you with the best possible care. If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policy. Payment for services is due at the time services are rendered. We accept cash, checks, Visa, MasterCard, Discover and CareCredit. We will be happy to help you process your insurance claim for reimbursement. Unpaid account balances older than 90 days will be placed with our collection agency, RMG (Receivables Management Group) for collection. Charges may also be made for broken/missed appointments or appointments that are cancelled with less than 24 hour notice at a charge of $ Should there be a returned check, our fees are $45.00, plus the amount of your check to be paid by cash, money order or cashier s check. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. As a patient of Foot and Ankle of West Georgia PC or Foot and Ankle of West Georgia LLC, you must realize 1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. 2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies that pay a percentage (such as 50-80%) of U.C.R.. U.C.R. is defined as usual, customary, and reasonable. This statement does not apply to companies that reimburse on an arbitrary schedule of fees, which bears no relationship to the current standard and cost in the area. 3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover, such as routine foot care. We must emphasize that our relationship is with you, not your insurance company. While the filing of our insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. If you have any questions or any uncertainty regarding your insurance coverage, please do not hesitate to ask us. We are here to serve you. 5

6 NOTICE OF PRIVACY PRACTICE This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully. TREATMENT: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. PAYMENT: Your health information may be used to seek payment from your health plan, automobile insurer, or from credit card companies that you may use to pay for services. HEALTH CARE OPTIONS: Your health care information may be used as necessary to support day-to-day activities and management of Foot and Ankle of West Georgia PC for example; information on services may be used for budgeting, financial reporting and activities to promote quality. LAW ENFORCEMENT: Your health care information may be disclosed to law enforcement agencies to support government audits, and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting. PUBLIC HEALTH REPORTING: Your health care information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the states public health department. OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: Use of personal health information for marketing and fundraising is restricted and you must be given the opportunity to opt out. This will be done in writing. Individuals have the right to prevent disclosure of records for any treatments they have personally paid for out-of-pocket. If you change your mind after authorizing a use of disclosure information you may submit a written revocation of the authorization. However, your written revocation will not affect or undo any use or disclose that occurred prior to your decision to revoke authorization. ADDITIONAL USES OF INFORMATION: Appointment reminders BREACHES OF SECURITY: We are required by law to notify you of security breaches that may expose your personal health information to those who have no legal right to see it. Our system is encrypted and we have measures in place to prevent this from happening. INDIVIDUAL PATIENT RIGHTS: 1. The right to request restrictions on the use and disclosure of your PHI (protected health information) 2. The right to receive confidential communications concerning your medical condition or treatment. 3. The right to inspect or copy your PHI. 4. The right to amend or submit correction for your PHI. 5. The right to receive an accounting with regard to how and to whom your PHI has been disclosed. 6. The right to receive printed copy of this notice. DUTIES OF FOOT AND ANKLE OF WEST GEORGIA, P.C. AND FOOT AND ANKLE OF WEST GEORGIA LLC: We are required by law to maintain the privacy of your PHI and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices outlined in this notice. RIGHT TO REVISE PRIVACY PRACTICES: As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes may be required by changes in the Federal and State law. Upon request we will provide you with the most recently revised notice on any visit. RIGHT TO INSPECT PROTECTED HEALTH INFORMATION: You may generally inspect or copy the PHI we maintain. As permitted by Federal Regulation, we require that these requests be submitted in writing. You may obtain a form to request access to your records by contacting the front desk receptionist, the office manager or the privacy official. We will review your request and get back to you as soon as possible. COMPLAINTS: If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Kathryn Hendon, Assistant Office Manager Foot and Ankle of West Georgia P.C Warm Springs Road Ste A Columbus, GA You will not be penalized or otherwise retaliated against for filing a complaint. 6