Patient Registration Form

Authorization and Request of Release of Medical Records
Date

Month Day Year
Date
Name

First Name Last Name
SS#
DOB

Month Day Year
Date
Holder of medical records:
I hereby request and authorize the above mentioned holder to release the following information, as specified below:
Item(s)
Patient/Guardian signature:

Clear
Witness:
Date

Month Day Year
Date
Autorizacion y Solicitud De Liberacion De Registros Medicos
Fecha

Month Day Year
Date
Nombre del paciente

First Name Last Name
SS#
Fecha de Nacimiento
Titular de registros medicos:
Doy Autorizacion al titular mencionado antierormente para recibir mi historia medica.
Firma del paciente:

Clear
Fecha:
PATIENT ACKNOWLEDGEMENT AND RECEIPT OF PRIVACY PRACTICES
I have read and received a copy of the notice of privacy practices.
Name

First Name Last Name
Signature of patient:

Clear
Date:

Month Day Year
Date
Witness:
PRACTICA DE PRIVACIDAD
Yo he leido y recibido una copia del aviso de practicas de privacidad.
Nombre del paciente

First Name Last Name
Firma del Paciente

Clear
Fecha:

Financial policy
Welcome and thank you for choosing our office for your Podiatric foot care needs. In our effort to provide personalized patient care in the most efficient and economical manner possible, we ask that you take a few moments to read our Financial Policy, fill out the demographic and health history forms for your medical file.

If at any time you have a question regarding our office policies do not hesitate to contact us and we will be happy to help you.

Your clear understanding of our Financial Policy is important to our professional relationship. We are a Medicare provider and also a provider for most PPO and HMO plans in our area. It is your responsibility to make sure we are on your insurance plan, and if we are not then you will be providing our self-pay amounts. If your insurance requires a referral or prior authorization, it is your responsibility to make sure that it is in place prior to your appointment. We will be glad to assist you if you need help.

We will bill your insurance company as a courtesy to you. All co-payments are due at the time of yourvisit. If you have an unmet deductible we pre-collect the charges incurred that your insurance will apply towards your deductible.

If you have a secondary insurance company, we will bill them one time. If your secondary insurance does not pay the balance due within 45 days, the balance will be billed to you and due at that time.
Balances/Collection Fees: If balances are not paid within 14 days from the statement date a $12.00 rebilling fee will be added to each additional statement sent for the unpaid balance. A consistent attempt will be made to collect outstanding account balances. Past due accounts, more than 90 days, will be turned over to our collection agency and a 35% fee of the balance due will be added to cover collection costs.

Complete payment for all podiatry soft goods, medical products and supplies at due at the time they are dispensed.

I have read the above policy and understand my financial responsibility to Atlanta Podiatry Specialists, LLC. and Dr. Mashail Manzur, DPM for medical services provided. I agree to pay Dr. Manzur, any balance due/or unpaid by my insurance carrier for myself or the below named person.
Financially Responsible Party:
Patient Name

First Name Last Name
Signature:

Clear
Parent or Authorized Representative
Date:

Month Day Year
Date
Upload a copy of your ID/ Drivers License/ Passport

Browse Files

Cancel of
Upload a copy of your Insurance Card

Browse Files

Cancel of
Should be Empty: