progressivefootcare.com-Patient Registration Form

Patient Registration Form

Patient Information
Name

First NameMiddle NameLast Name
Date of Appointment

MonthDayYear
Sex
Marital Status
Date of Birth

MonthDayYear
SSN#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone
Email
example@example.com
Refereed By
Primary Care Physician
Primary Care Physician Phone

Area CodePhone Number
Pharmacy Name
Pharmacy Phone

Area CodePhone Number
Pharmacy Address
Patient Employer/School Information
Employer Name
Professional Title
Employer Phone

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name
School Phone

Area CodePhone Number
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship to Patient
Emergency Contact Home Phone

Area CodePhone Number
Emergency Contact Cell Phone

Billing and Insurance

Primary Health Insurance
Primary Insurance Name

First NameLast Name
Primary Plan Name
Primary Subscriber ID
Primary Group No.
Insured's Employer/School
Insured's Name

First NameLast Name
Relationship to Patient
Insured's Phone

Area CodePhone Number
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's SSN #
Insured's Birth Date

MonthDayYear
Secondary Insured Information
Secondary Insurance Name

First NameLast Name
Secondary Plan Name
Secondary Subscriber ID
Secondary Group ID
Insured's Employer/School
Insured's Name
Relationship to Insured's
Insured's Phone Number

Area CodePhone Number
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's SSN
Insured's Birth Date

MonthDayYear
Responsible Party
Billing Name
Phone

Area CodePhone Number
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Patient or Authorized Guardian
Date

MonthDayYear

HIPPA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/ date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or health care operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPPA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the infoemation for treatment, payment, or health care oprations.

By signing this form, you consent to our use and disclosure of protected healthcare information and potentially anonymous usege in a publication.You have the right to revoke this consent in writing, signed by you. However , such a revocation will not be retroactive.

By Signing this for, I understand that:
- Protected health information may be disclosed or used for treatment,payment,or healthcare operation.
- The Practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information but the practice does not have to agree to those restriction.
- The patient has the right to revoke this consent in writing at any time and all disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
May we phone ,email, or send a text to you to confirm appointment?

YesNo
May we leave a message on your answering machine at home or on your cell phone?

YesNo
May we discuss your medical condition with any member of your family?

YesNo
If YES, please name the members allowed:
This consent was signed by:
Signature
Date

MonthDayYear

PROGRESSIVE PODIATRY & FOOT SURGERY

19 WEST 34TH STREET SUITE 608

NEW YORK, NY 10001

212-244-7670

Authorization for Use of Signature On File for Claim Authorization
Social Security Number
Name

First NameMiddle NameLast Name
I,
Authorize
Mark the section "ENROLL'S OR AUTHORIZED PERSON'S SIFNATURE"with the notation "SIGNATURE ON FILE"

This section authorizes:

1. The release of any medical information necessary to process this claim.
2. Payment of medical benefits to the undersigned physician or supplier of services described below.

This authorization will remain in force until terminated in writing the enrollee.
Enrollee Signature
Agreement for Doctor to Receive Isurance Checks

I,the undersigned, realize that I may receive checks from my insurance carrier for services that are provided in this office. I understand that it is my responsibility to sign the back of those checks and forward them, along with the Explaination of Benefits(EOB) that is attached to the check andall corresponding pages, tothe above office with in 7 days. If I fail to do so.I will beresponsible for the full amount of the bill plus any interest and legal fees incurred for collecting them.
Patient Signature
Date

MonthDayYear
Should be Empty:

Rows	Yes	No
Do you currently or have you ever worn orthotics?
Does your foot pain limit your desired activity?
Are your first steps out of bed in the morning painful?
Have you ever had any other foot problems?

Rows	Name	Dosage	Frequency
1
2
3
4
5

Rows	Reason	Date
1
2
3
4
5