MIDWEST FOOT & ANKLE CLINIC

Transcription

1 MIDWEST FOOT & ANKLE CLINIC The office of James H. McClain, DPM Dr. McClain and staff welcome you to our office. Please answer these questions to help us get to know you better. If you need help, do not hesitate to ask. We are pleased to have you with us. PATIENT INFORMATION NAME: MALE FEMALE SOC. SEC. NUMBER: - - BIRTHDATE: / / SINGLE MARRIED SEPARATED DIVORCED WIDOWED HOME PHONE: ( ) - CELL PHONE: ( ) - HOW DID YOU HEAR ABOUT DR. MCCLAIN? PHYSICAL ADDRESS: If mailing address is same as physical, check here MAILING ADDRESS: EMPLOYER: OCCUPATION: ADDRESS: WORK PHONE: ( ) - EMERGENCY CONTACT INFORMATION NAME: RELATION TO PT: ADDRESS: _ PHONE: ( ) - INDIVIDUAL RESPONSIBLE FOR ACCOUNT If same as patient, check here NAME: RELATIONSHIP: SOC. SEC. NUMBER: - - BIRTHDATE: / / ADDRESS: EMPLOYER: OCCUPATION: ADDRESS: WORK PHONE: ( ) - SPOUSE INFORMATION NAME: BIRTHDATE: / / SOC. SEC. NUMBER: - - EMPLOYER: ADDRESS: WORK PHONE: ( ) - Page 1

2 PODIATRIC HISTORY Patient Name: DOB: What is the chief complaint that brings you here today? (Include foot, ankle, knee, thigh, and hip complaints) How long have you had your current condition? Is your current condition the result of an accident? YES NO If so, date of injury: How you been previously treated for this condition? If yes, by whom? Have you ever been to a podiatrist before? YES NO If yes, whom? Date of last visit: Do you have a family history of diabetes? YES NO If yes, who in your family had diabetes? Cigarette/tobacco use: YES NO Years used: Currently using? YES NO Alcohol: YES NO If yes, how often? Athletic activities in which you participate: Description Frequency Please indicate which foot/ankle problems you currently have or have had in the past. Ankle pain YES NO Athlete s foot YES NO Bunions YES NO Corns/calluses YES NO Flat feet YES NO Foot or leg cramps YES NO Heel pain YES NO Ingrown toenails YES NO Plantar s warts YES NO Swelling in feet/ankles YES NO Height Weight Page 2

3 MEDICAL HISTORY Check YES or NO to indicate if you have had any of the following: Patient Name: DOB: High Blood pressure YES NO Diabetes YES NO Low Blood pressure YES NO Blood disease YES NO Stomach Ulcer YES NO Tuberculosis YES NO Heart Disease YES NO Epilepsy YES NO Venereal disease YES NO Difficulty healing YES NO Shortness of breath YES NO Anemia YES NO Arthritis YES NO Asthma YES NO Varicose veins YES NO Back problems YES NO Bleeding disorder YES NO Chest pain YES NO Chemical dependency YES NO Fainting YES NO Circulatory problems YES NO Eye problems YES NO Headaches YES NO Gout YES NO Hepatitis YES NO Liver Disease YES NO Kidney problems YES NO Phlebitis YES NO Nervous problems YES NO Stroke YES NO Cancer YES NO Rheumatic fever YES NO Respiratory disease YES NO Anxiety YES NO Surgeries you have had: Description Date Have you been recently hospitalized not including surgeries listed above? YES NO Reason: _ Dates admitted: Family Physician: Address: Date of last visit: City State Are you now or have you been under a doctor s care for any reason over the past 2 years? YES NO If Yes, Please explain: Page 3

4 MEDICATIONS Patient Name: DOB: Include prescriptions, over the counter medications and Vitamins: Pharmacy Name: Location: Phone #: ( ) - City State ALLERGIES Adhesive Tape YES NO Novocain YES NO Local Anesthetics YES NO Aspirin YES NO Codeine YES NO Demerol YES NO Iodine YES NO Sulfa YES NO Penicillin YES NO Cortisone YES NO Antibiotics YES NO Seafoods YES NO Morphine YES NO Other: CONSENT FOR TREATMENT I hereby give my permission to Dr. McClain to administer treatment and to perform minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot condition. I authorize payment directly to the physician and I am responsible for non-covered services. I release medical information for filing and receiving payments on insurance claims. I have read and understand the office policy and procedures brochure. Patient/Guardian Signature: Date: Page 4

5 MIDWEST FOOT & ANKLE CLINIC The office of James H. McClain, DPM Acceptance of Insurance Assignment and Financial Policies Please initial each line showing you agree to abide with the following: I authorize Midwest Foot & Ankle Clinic and its agents to furnish my insurance companies with all necessary information concerning diagnosis and treatment for myself or dependents under compliance of the Health Insurance Portability and Privacy Act of 1996 (HIPAA). I assign the medical and/or surgical benefits that my dependents and I am entitled to under my health insurance plan to Midwest Foot & Ankle Clinic and treating physicians. I agree to pay all balances accrued with Midwest Foot & Ankle Clinic and my treating physicians for services rendered in a timely manner and understand that I am responsible for all co-payments, deductibles, and co-insurance at the time of service. Cash, personal checks, cashier s checks, money orders, VISA, MasterCard, and Discover are all accepted (credit card fees apply per transaction). A copy of my credit card will be maintained on file for all outstanding balances. Midwest Foot & Ankle Clinic does not generally arrange payment plans. In situations of extreme financial hardship, I will discuss my situation with the treating physician and/or the office manager prior to my account going into delinquency. In the case of divorced parents, payment is expected from the person signing this document and will be considered the guarantor for all payments for any services provided. Midwest Foot & Ankle Clinic will not recognize any divorce decrees regarding reimbursement for medical services for any minor child of divorced parents. I understand that my relationship with Midwest Foot & Ankle Clinic may be terminated at any time by the organization for any reason, including account delinquency without any attempt to pay. An annual collection fee of 21.6% will be applied to all outstanding balances past 60 days. Any balance not paid after 90 days may be referred to an attorney for collection. All legal and collection fees, including a $20 late fee should my account be sent to collections, will be the guarantor s responsibility. Patient Name Signature of Patient/Responsible Party Printed Name Date Page 5

6 MIDWEST FOOT & ANKLE CLINIC The office of James H. McClain, DPM Assignment of Benefits and Release of Medical and Plan Documents I (the patient) have insurance and/or employee health care benefits coverage with (insurance company), and hereby assign and convey directly to Midwest Foot & Ankle Clinic all medical benefits and/or insurance reimbursement otherwise payable to me for services rendered from Midwest Foot & Ankle Clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments and understand that these balances are due within 90 days from the date of an insurance payment and/or denial. If outside collections are necessary, I will be responsible for all collection and legal fees. I hereby authorize Dr. McClain to release all medical information necessary to process this claim within HIPAA guidelines. I hereby authorize any plan administrator or fiduciary, insurer, and my attorney to release to Midwest Foot & Ankle Clinic any plan documents, insurance policy, and settlement information in order to claim such medical benefits, reimbursement, or applicable release. Requests for such information must be submitted in writing. I authorize the use of my signature on all my insurance or employee health benefit claim submissions. I have received the practice s HIPAA guidelines and a signed receipt of these guidelines is on file in my medical record. I agree to cooperate with the staff of Midwest Foot & Ankle Clinic in their pursuit of reimbursement from my insurers and/or employee health care plan, including, if necessary, bringing suit with Midwest Foot & Ankle Clinic against insurers and employee health care plan. In this situation, I understand that the suit would be in my name, but at the expense of Midwest Foot & Ankle Clinic. This assignment will remain in effect until revoked by me in writing. A copy of this assignment is to be considered as valid as the original. I have read and fully understood this agreement. Patient Name Date Signature of Patient/Responsible Party Printed Name Date Page 6