Forms

 
 
 
 
 
 
 
 
 
 
 
Gender:
 
 M  F 
 
 
 
 
 
 Married  Single  Other 
 
 
RACE/ETHNICITY:
 
 White  American Indian or Alaskan  Asian  Black or African American  Hispanic or Latino 
 
 
Do you want access to your online medical records through our office?
 
 Yes  No 
 
 
If YES, please provide a valid Email Address:
 
You will receive an invite via the email provided above.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Referred By:
 
 Family Member  Phonebook  Newspaper  Insuranc  Internet 
 
 
 
 
 
 
Prescriptions: I give permission for the physician and his office staff to access my prescription history
 
 Yes  No 
 
 
 
 
 
Leaving Messages: Our office makes reminder calls prior to your next visit. Please initial and date below giving us permission to leave a message or any medical information as necessary on your answering machine.
 
 
 
 
HIPAA release of protected personal patient information: Are there any family members or individuals that you would like our office to give your personal information?
 
 
 
 
**Are you a minor?
 
 Yes  No 
 
 
 
 
 
The Foot & Leg Specialty Center - Podiatrist in New Port Richey, FL
CONSENT & FINANCIAL STATEMENTS
CONSENT TO TREAT: I/We do hereby consent to and authorize the performance of all treatments, surgeries and medical services deemed advisable by the physicians and staff of the Foot and Leg specialty center to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. I understand that I am directly responsible for all charges incurred for medical services for myself and my dependents regardless of insurance coverage.
INSURANCE & FINANCIAL INFORMATION:
Insurance assignment and release: I certify that I have insurance and assign direct payments to the fore mentioned company and assign rights to further appeal any denials of those claims or actions on my behalf. Further, I authorize the doctor or members of his staff to release any information needed to determine benefits payable to my insurance carrier. I understand and agree that health and accident insurance policies are an arrangement between the carrier and the patient and accept financial responsibility of services provided if my insurance company deems the services non-payable or does not process the claims in a timely manner (typically 60 days). Additionally, I am aware that I will be responsible for any co-pay and deductible amounts.
SELF PAY: I understand that I am responsible for charges incurred at the time of my visit and are due at the time of my visit unless other arrangements have been arranged. I agree and understand that I may be charged a 1.5% interest rate per month on any unpaid balance and that I am responsible for any costs incurred in collection of said balances should that become necessary.
Patient OR Legal Guardian Signature _________________________________________ Date__________________