New Patient Intake Form - Dr. Eric Tucker

Eric A. Tucker, D.P.M.

PODIATRY & SPORTS MEDICINE
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Hone Phone Number
Please enter a valid phone number.
Email Address:*
example@example.com
Date of Birth:*

MonthDayYear
Date
Sex:*

MaleFemaleN/A
SS #
Marital Status:*

SingleMarriedOther
Employer:*
Occupation:*
Spouse's Name:*
Emergency Contact Name:*
Relationship:*
Emergency Contact Phone #:*
Whom may we thank for referring you?:*
Phone #:
Preferred Pharmacy:*
Phone #:*
Pharmacy Phone Number
Who is responsible for this account?*
Relationship to Patient:
Does patient have insurance coverage:*

YesNo
Primary Insurance:*
Primary Insurance ID#:*
Please do not include "-" on Medicare ID #
Secondary Insurance:*
Secondary Insurance ID#:
I, the undersigned certify that I (or my dependent) have insurance coverage that is assign directly to Dr. Rick A. Tucker all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for my deductible, co-payments, and all services that are not covered by my insurance company. I hereby authorize Dr. Tucker and his billing staff to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Signature*

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MEDICAL HISTORY:
What is the reason for your office visit?:*
Height:*
Weight:*
Who is your medical doctor?:*
Phone Number:*
Medical Doctor Phone Number
Surgeries you have had in the past:*
Hospitalizations other than for the surgeries listed above:*
List any medications you are taking on a regular basis:*
Do you smoke?:

YesNo
If yes, how many packs a day?
Have you ever had any of the following? (Please check):

High Blood PressureLiver ProblemsKidney ProblemsCancerBleeding ComplicationsHIV PositiveHeart ProblesArthritisGoutGastrointestinal ProblemsLung ProblemsSwelling FeetDiabetesOther
Are you allergic to any of the following?

Tape / AdhesiveDemerolNovovaineSeafoodAspirinIodinePenicillinCodeineLocal AnestheticsSulfaOther
I certify that the above information is true and correct to the best of my knowledge. I give permission to Dr. Tucker to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet:
Signature*

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Patient Acknowledgement

Appointment Cancellation Policy
Dear Patient,

To ensure we can provide the best care for all our patients, we have instituted an Appointment Cancellation Policy. A cancellation made with less than 24 hours’ notice significantly limits our ability to offer the appointment slot to another patient in need.

Policy Details:
- 24-Hour Notice Requirement:
  Please notify our office at least 24 hours in advance if you need to reschedule your appointment. This will allow us the opportunity to provide care to another patient. A message can always be left with the answering service to avoid a cancellation fee being charged.
- Missed Appointment Fee:
  A “No-Show,” “No-Call,” or missed appointment, without proper 24-hour notification, may be assessed an $85 fee.
- Insurance Disclaimer:
  This fee is not billable to your insurance.
- Reminder Calls:
  As a courtesy, we make reminder calls for appointments one to two days in advance. Please note that if a reminder call or message is not received, the cancellation policy remains in effect.
If you have any questions regarding this policy, please let our staff know, and we will be glad to clarify any questions you have. A copy of this policy will be provided to you. Please sign and date below to acknowledge your understanding of this policy.

Acknowledgement:

I have read and understand the Appointment Cancellation Policy, and I acknowledge its terms. I also understand and agree that such terms may be amended from time to time by the clinic.
Signature*

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Your Rights Regarding Your Protected Health Information (PHI)
- Right to Access Your PHI
  You have the right to view and obtain a copy of your protected health information. However, federal law restricts access to certain records, including psychotherapy notes, information prepared in anticipation of legal actions, and any PHI that is legally restricted.
- Right to Request Restrictions on Use and Disclosure
  You can ask us not to use or share parts of your PHI for treatment, payment, or healthcare operations. You can also request that we do not share your information with certain family members or friends involved in your care. Your request must specify the restriction and to whom it applies. While we will consider your request, your physician is not required to agree if they believe it is in your best interest to use or disclose your information. If you disagree, you have the right to seek care from another healthcare provider.
- Right to Confidential Communication
  You have the right to request that we communicate with you about your health information in a confidential manner, such as through alternative means or at a different location.
- Right to Receive a Copy of This Notice
  You can request a paper copy of this notice at any time, even if you have previously agreed to receive it electronically.
- Right to Request Amendments to Your PHI
  If you believe your PHI is incorrect or incomplete, you can request an amendment. If we deny your request, you have the right to submit a statement of disagreement, and we may provide a rebuttal. A copy of any rebuttal will be given to you.
- Right to an Accounting of Disclosures
  You may request an accounting of certain disclosures of your PHI that we have made, if any.
- Right to Changes in This Notice
  We reserve the right to change the terms of this notice at any time. If changes are made, you will be notified by mail. At that point, you have the right to object or withdraw your consent as outlined in this notice.
Complaints:

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of Health and Human Services. You can file a complaint with us by notifying our privacy contact. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on April 14, 2003.

We are required by law to maintain the privacy of your protected health information and provide you with this notice outlining our legal duties and privacy practices. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone using our main contact number.

Acknowledgement of Receipt:

I acknowledge that I have received and understand the "Your Rights Regarding Protected Health Information" notice.
Signature*

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Should be Empty:

Eric A. Tucker, D.P.M.

MEDICAL HISTORY:

Patient Acknowledgement