Forms

 
 
 
 
 
 
 
 
 
 
 
 
Gender:
 
 M  F 
 
 
 
 
 
 Married  Single  Other 
 
 
RACE:
 
 African American  American Indian or Alaskan  Asian  Hispanic  Mixed Race  White  Other 
 
 
Ethnicity:
 
 Hispanic  Not Hispanic  Refuse to report 
 
 
 
 
 
 
 
 
 
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 for patient portal.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Referred By:
 
 Family Member  Phonebook  Newspaper  Insurance  Internet 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CONSENT & FINANCIAL STATEMENTS
Patient consent for Treatment
  1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by the Foot & Leg Specialty Center and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I understand that no guarantee has been or can be made as to the results of the treatments or examinations at The Foot & Leg Specialty Center/James V Stelnicki, DPM PA.
  2. I consent to the use and disclosure of my/the patient's protected health information for purpose of obtaining payment, treatment and health care operations consistent with The Foot & Leg Specialty Center notice of privacy practices, financial policy notice and release of information.
  3. I authorize payment of medical benefits to The Foot & Leg Specialty Center/James V Stelnicki, DPM PA or their designee for services rendered.
  4. I give permission to obtain all my medication/ prescription history when using an electronic system to process prescription for my treatment.
 
 
 
 
Authorization for release of information: I authorized a release of my protected health information to
SELF PAY:
If you are self pay patient, you will be required to pay for the office visit before services ate rendered.
In addition, any remaining balance on your account will be collected at discharge.

Insurance policy:
If you are an insurance patient, it is our policy to file for insurance as a courtesy to you, if we have accurate and complete insurance information.

Deductibles, Co Payments and co-insurance will be collected at the time of services and or due within 60 days of insurance processing. Non covered services by your insurance company will be your responsibility at the time of services.

To help in this policy, we ask that you assist us by
  1. Providing us with current and updated information on yourself and your insurance company,
  2. Present an updated photo identification card and insurance card when changes are made.