baybreezefeet.com-new-patients

Rows	Yes	No
Fever
Chills
Unexplained weight loss

Rows	Yes	No
Cough
Shortness of breath
Wheezing

Rows	Yes	No
Back pain
Joint pain or swelling
Muscle pain

Rows	Yes	No
Visual changes
Eye pain

Rows	Yes	No
Hearing loss
Ear pain

Rows	Yes	No
Anxiety
Depression

Rows	Yes	No
Chest pain or palpitation:
Lower extremity edema or swelling
Experience thigh or leg pain when walking distances

Rows	Yes	No
Rash
Bothersome skin lesions
Slow healing wounds

Rows	Yes	No
Easy bruising or bleeding
Swollen glands

Rows	Yes	No
Itchy/Watery eyes
Recurrent infection

Dr. Maurice W. Aiken
Bay Breeze Foot & Ankle Specialists, P.L.L.C.
1022 Main St. Suite L, Dunedin, FL 34698
Phone(727) 734-5575 * Fax (727)733-4147
www.BayBreezeFeet.com

Summary Of Notice Of Privacy Practice Karen T., Privacy Officer

This summary is provided to help you understand the Notice of Privacy Practices and describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully, the privacy of your medical information is important to us.

OUR LEGAL DUTY: We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. Copies of our complete notice of privacy practices, which contains a detailed description of how our office will protect your health care information, are located in the reception area and each treatment room. You may request a copy of our notice at any time.

USES AND DISCLOSURES OF HEALTH INFORMATION: We will use and disclose your health information in order to treat you or to assist other healthcare providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other healthcare providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training.

USES AND DISCLOSURES BASED ON YOUR AUTHORIZATION: Except as stated in more detail in the notice of privacy practices, we will not use or disclose your health information without your written authorization.

USES AND DISCLOSURES NOT REQUIRING YOUR AUTHORIZATION: In the following circumstances, we may disclosure protected health or financial information without your written authorization: To family members or close friends who are involved in your health. For certain limited research purposes. For purposes of public health and safety. To government agencies for purposes of their audits, investigations, and other oversight activities. To government authorities to prevent child abuse or domestic violence. To FDA to report product defects or incident. To law-enforcement authorities to protect public safety or to assist in apprehending criminal offenders. When required by court orders, search warrants, subpoenas, and as otherwise required by the law.

AS OUR PATIENT YOU HAVE THE FOLLOWING RIGHTS: To have access to and/or a copy of your health information. To receive an accounting of certain disclosures we have made of your health information. To request restrictions as to how your health information is used or disclosed. To request that we communicate with you in confidence. To request that we amend your health information. To receive notice of our privacy practices.

If you have a question, concern or complaint regarding our privacy practices, please refer to our detailed Notice of Privacy Practices or contact a staff member.

Podiatric Medicine * Sports Medicine * Surgery of the Foot & Ankle * Alternative Foot Care

Dr. Maurice W. Aiken
Bay Breeze Foot & Ankle Specialists, P.L.L.C.
1022 Main St. Suite L, Dunedin, FL 34698
Phone(727) 734-5575 * Fax (727)733-4147
www.BayBreezeFeet.com

Patient's Name (Please Print)
Date of Birth

MonthDayYear
All signatures below are the patient's unless the patient is unable to understand or sign. If a legally authorized representative is signing for the patient, please also print name and state relationship. By signing each section you are stating you fully understand and agree to that section of this document.
Acknowledgement of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices for Bay Breeze Foot & Ankle Specialists prior to my signing this, and that I have read or had the opportunity to read if I so choose and understand the notice.
Patient Signature

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Date

MonthDayYear
Consent for Medical and Billing Records Access
I allow (Patient Designee) to have access to my medical records
Relationship to Patient Designee
Patient Signature

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Date

MonthDayYear
Financial Policy
An insurance policy is an agreement between you and your insurance company. Payment for services rendered and reimbursement from the insurer is ultimately the responsibility of the patient. If your insurance company requires a referral, it is your responsibility to obtain the necessary referrals for each visit. If we do not participate in your plan, payment is expected when services are rendered. Copays, deductibles, and charges for non-covered services are due at time of visit. Interest may be added to past due accounts in the amount of 1.5% monthly. If your account is sent out for collection, you will be responsible for and additional collection costs and attorney fees that may be incurred, including past due interest charges and a late payment service charge.
Patient Signature

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Date

MonthDayYear
Medicare & Commercial Insurance Assignment of Benefits

I request that payment of authorized Medicare/Commercial benefits be made directly to me or on my behalf to Bay Breeze Foot & Ankle Specialists, PLLC, for any services or products furnished me by it's physicians. I authorize any holder of medical information about me to release to the Health Care Financing Administration and it's agents any information needed to determine these benefits, or the benefits payable for related services.
Signature

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Date

MonthDayYear

Dr. Maurice W. Aiken
Bay Breeze Foot & Ankle Specialists, P.L.L.C.
1022 Main St. Suite L, Dunedin, FL 34698
Phone(727) 734-5575 * Fax (727)733-4147
www.BayBreezeFeet.com

Financial Policy

Your understanding of our financial policies is an essential element of your care and treatment.

If you have any questions, please discuss them with our front office staff or supervisor.
- As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office.
- Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check.
- Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.
- We have made prior arrangement s with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible.
- If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service.
- All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered . Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.
- You must inform the office of all insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied.
- For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.
- There are certain elective surgical procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.
- Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office.
- There is a service fee of $30.00 for all returned checks. Your insurance company does not cover this fee.
- Patients will be charged a FEE for any missed appointment that does not receive a 24-hour cancellation notice.
Signature

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Date

MonthDayYear
Podiatric Medicine • Sports Medicine • Surgery of the Foot & Ankle • Alternative Foot Care
Should be Empty:

Rows	Yes	Year ( If Yes)
Angioplasty
Appendectomy
Cholecystectomy (gallbladder)
Heart Stents/Open Heart
Hernia Umbilical/Inguinal
Hysterectomy
Joint Replaced (hip or Knee)
Lung Surgery
Mastectomy
Thyroidectomy
Tonsillectomy
Vascular
Other

Rows	Yes	Detail	Time Limit
None
Occasional Walking
Regular Walking
Running
Gym Workout
Swimming
Biking
Other

Rows	Medication	Size(mg./tsp)	#Taken	How Often	Oral, Topical,or Inject	Reason
1
2
3
4
5
6
7
8
9
10

Rows	Allergies	Reaction(i.e. rash, fever,vomiting,GI upset, hives
Penicillin
Aspirin
Demerol
Codeine
Sulfa
Tetanus
Tape
Iodine
Local Anesthetics
Other

Rows	Yes	No
Nasal congestion
Mouth lesions
Sore throat
Difficulty swallowing

Rows	Yes	No
Frequency in urination
Sweating
Excessive thirst
Cold intolerance
Heat intolerance

Rows	Yes	No
Diarrhea
Nausea
Constipation
Blood in stools
Abdominal pain

Rows	Yes	No
Headaches
Numbness or Tingling
Gait instability
Difficulty Speaking
Confusion
Seizures

Family History