FAMILY FOOT AND ANKLE CENTER

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FAMILY FOOT AND ANKLE CENTER Powered By Docstoc
					              Family Foot & Ankle Care
                     Podiatric Medicine & Surgery
                              Joseph M. DiFranco, DPM, AACFAS


                            NEW PATIENT CONSULTATION FORM

Date: _______________

Last Name: ____________________________ First Name: _____________ MI: _____

DOB: _________________ Male: _____          Female: _____       Age: ______

Referred By: _________________________          Family Dr: _______________________

Current foot problems: _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Current Medications: _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Medical Conditions/History: ____________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

     Please use circles and arrows to indicate painful, injured or problem area(s)
                                                                  REGISTRATION FORM
                                                                                  ( Please Print)

Today’s date:                                                                                                           PCP:

                                                                   PATIENT INFORMATION
Patient’s last name:                                     First:                         MI:        Sr., Jr., Etc.              Date of Birth (mm/dd/yy): __________________

                                                                                                                                                   Sex:          Male           Female
Social Security No.:            Marital Status:                                                                                      Are you retired:
                                   Single             Married          Divorced          Widowed                Separated
                                                                                                                                           YES                   No

Street address:                                                                         Home Phone No.:                                        Cell Phone No.:

                                                                                        (              )                                       (          )

City:                                             State:                                                            Zip Code:



Employer:                                         Employer’s Address:                                                                          Employer phone no.:

                                                                                                                                               (      )

Other family members seen here:


                                                                  INSURANCE INFORMATION
                                                   Please give your insurance card or cards to the receptionist.

Person responsible for bill:        Birth date:               Address (if different):                                                          Home Phone No. (if different):

                                           /       /                                                                                           (          )

Relationship to Patient:            Self                      Parent                    Spouse                   Other




Is this patient covered by insurance?           Yes           No

Please list primary insurance name_________________________                     Please list secondary insurance name:_________________________________


Primary Ins Subscriber’s Name:             Subscriber’s S.S. no.:            Birth Date:                   ID No:                                   Group No:
                                                                                    /         /

Patient’s relationship to subscriber:             Self                 Spouse               Child               Other

Secondary Ins Subscribers Name:                           Subscribers’ SS No.:                    Birth Date:                   Policy No.:                      Group No.:

                                                                                                      /         /

Patient’s relationship to subscriber:             Self                 Spouse               Child               Other


                                                                   IN CASE OF EMERGENCY
Name of friend or relative (not living at same address):                            Relationship to patient:                    Home phone no.:

                                                                                                                                (          )

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am
financially responsible for any balance. I also authorize Family Foot and Ankle Care or insurance company to release any information required to process
my claims.


  Patient/Guardian signature                                                                                                        Date
          ACKNOWLEDGEMENT OF RECEIPT OF NOTICE
                   OF PRIVACY PRACTICES
    ERIE PHYSICIANS NETWORK, PC/FAMILY FOOT AND ANKLE
                           CARE
Ihereby acknowledge that I have been provided with a copy of Erie Physician’s Network,
PC/Family Foot and Ankle Care (the “Practice) Notice of Privacy Practices (the “notice”). The
Notice contains information regarding potential uses and disclosures of my protected health
information (as that term is defined under the Health Insurance Portability and Accountability
Act of 1996 “HIPAA”) that may be made by the Practice and of my rights and the Practice’s
legal duties with respect to my protected health information. I have had the opportunity to
review the Notice and take a copy with me if I so choose.

Patient’s Name (PRINT) _________________________________ Date _______________

Signature of Responsible Party/Patient__________________________________________
___________________________________________________________________________

IF PATIENT/RESPONSIBLE PARTY REFUSES TO SIGN ACKNOWLEDGEMENT, COMPLETE THIS
SECTION:
Patient refuses to sign Acknowledgement
Erie Physicians Network, PC/Family Foot and Ankle Care and its employee_____________
Have made the following efforts to attempt to obtain a signature from the patient/responsible
party:
    1. ___________________________________________________________________
    2. ___________________________________________________________________
    3. ___________________________________________________________________
___________________________________________________________________________
I hereby authorize you to disclose, orally or in writing, all the facts pertaining to my past,
present or future condition, treatment and services rendered. This includes diagnosis,
prognosis, care and treatment, reports, testing and charges. I KNOW THAT THIS
INFORMATION MAY BE RELEASED TO ME, MY PHYSICIAN(S) AND MY INSURANCE
COMPANY. You may also release information to the following:

Name:                                    Relationship:                 Telephone:
_____________________________            ___________________           _____________
_____________________________            ___________________           _____________
_____________________________            ___________________           _____________

      •   May we leave a message on your answering machine? (circle)         YES / NO
      •   May we contact you at work?                                        YES / NO


I understand I may change this authorization in writing at any time.

Patient’s Signature X_________________________________Date X______________
                                                                  EPN
                                             EPN: FINANCIAL RESPONSIBILITY POLICY
                                                          Erie Physicians Network, PC
Consent to Services:
Patient hereby requests registration at an Erie Physicians Network, PC (referred to as EPN, PC in this document) office and voluntarily
consents to any facility services deemed necessary or advisable as determined by, as appropriate, the attending physician or his or her
assistants/designees, or employees or agents of EPN, PC, with appropriate clinical privileges. Patient (responsible party) acknowledges that
no guarantees have been made as to the results of treatment or examination at the EPN, PC office.
Payment Guarantee:
For and in consideration of services rendered by the EPN, PC office, patient (responsible party) hereby agrees to and guarantees payment of
all charges incurred for the account of the patient. Payment is due in full when services are rendered. If the patient is eligible with an EPN,
PC participating insurance company and identification is provided, the insurance company will be billed for the services rendered in lieu of
cash payment by the patient (responsible party).
Consent to Release Information:
The undersigned hereby authorizes the EPN, PC office to release to employer group, insurance companies, government agencies or other
third party payers and their agents information concerning diagnoses and procedures performed, medical care, advice, treatment, supplies or
other information that may be necessary for the purpose of determining eligibility and available benefits and obtaining payments on the
patient’s behalf for the health care services rendered to the patient. Patient (responsible person) acknowledges that he or she will be
financially responsible for charges incurred for the patient’s treatment if revocation or refusal to authorize the disclosure of the medical
records results in a payment denial of the insurance claim.
Medicare:
Patient certifies that the information given in applying for payment under Title XVIII (18) of the Social Security Act is correct. Patient
(responsible party) authorizes any holder of medical or other information about patient to release to the Social Security Administration or its
intermediaries or carriers any information needed for this or a related Medical claim. Patient (responsible party) requests that payment of
authorized benefits be made on his/her behalf to the name of provider of service for any services furnished to me by that provider of service.
Medigap:
Patient (responsible party) requests that payment of authorized Medigap benefits be made on my behalf to the provider of service for any
services furnished to me by that provider of service. Patient (responsible party) authorizes any holder of Medicare information about me to
release to (Medigap Name)_______________________________any information needed to determine these benefits payable for related
services.
Assignment of Insurance Benefits and Agreement to Pay Balance:
Patient (responsible person) irrevocably assigns and transfers to EPN, PC all right, title and interest to medical reimbursement benefits under
any and all applicable medical insurance policies covering patient, for the payment of hospital and medical care being provided. Patient
(responsible person) authorizes payment directly to EPN, PC of said medical reimbursement benefits. In the event that said medical insurance
coverage is not sufficient to satisfy the charge in full, patient (responsible person) acknowledges that the resulting balance is not covered by
this assignment and agrees to be fully responsible for the payment of any balance due. For any non-contracted payers, EPN, PC will submit a
courtesy claim. If no payment is received in sixty (60) days, the balance will be dropped to patient responsibility. Patient (responsible
person) acknowledges responsibility for any expenses incurred by EPN, PC for collecting any of the charges incurred on the account of the
patient. Such shall specifically include any attorney’s fees or any collection fees, or litigation and/or audit costs incurred by Erie Physicians
Network on collecting said bill.
These agreements and authorizations shall be valid for one (1) year from the date of patient/parent/guardian signature


___________________________________________________________________________________________________________________
Patient Name (Last, First, MI)   (print)                                                             Health Insurance Claim Number
___________________________________________________________________________________________________________________
Patient Signature (Parent/Guardian)                               Medigap Policy Number                                 Date
Please check the appropriate description of your relationship to the patient:
________________Self                       _________Parent/Legal Guardian of Minor             _______________Other (please explain)