OUR CANCELLATION / NO-SHOW POLICY

OUR CANCELLATION / NO-SHOW POLICY
DUE TO THE INCREASING NUMBER OF NO-SHOW AND SAME DAY CANCELLATIONS OF APPOINTMENTS, WE ARE INSTITTUING A NEW POLICY, EFFECTIVE IMMEDIATELY.
THE POLICY IS AS FOLLOWS:
1.Cancelled appointments within 24 hours of appointment time - $25.00 fee

2.No show for appointment time - $50.00 fee

3.Surgery cancellation within five days of schedule surgery time – $750.00 fee

4.Any forms or letters will charge accordingly.
OUR STAFF APPRECIATES YOUR UNDERSTANDING

Thank you
I have read and agree to the above policy.
Name

First Name Last Name
Date

Month Day Year
Date
Your payment information

We Accept
Card Number
Expiration Date

Month Day Year
Date
CCV
PATIENT INFORMATION
First:
M.I.
Last:
Preferred Name:
Sex

M F
Mobile Phone:
E mail:
example@example.com
Home Phone:
Work Phone:
Preferred method of communication:
Address:
Apt #
City:
Zip Code:
Emergency Contact:
Relationship:
Phone #
Alternative#
Patient relationship to Guarantor:

Self Spouse Child Other
Guarantor Name:
Guarantor Address:
Guarantor City:
State:
Guarantor DOB:
Sex:

M F
Social Security #:
Guarantor Phone:
Secondary Phone:
Patient's Ethnicity:
Language:
Patient's Race:
Primary Doctor:
Month
Year
How did you hear about us?

Google Yelp Website Insurance Referred by:
Pharmacy:
Phone Number:
Prescription History
In order to have the most current prescription information, we need to request the information electronically.
Do we have permission to do so?

Yes No
Signature:

Clear
Date:

Month Day Year
Date
Primary Doctor:
Phone No:
Date of last exam:

Month Day Year
Date
Describe the condition that brought you to this office:
If auto accident, date of accident

Month Day Year
Date
Previous care for this condition?

Yes No
Doctor:
Date:

Month Day Year
Date
HEIGHT:
Weight:
HAVE YOU RECEIVED THE FLU SHOT THIS YEAR?

YES NO
MEDICAL: (Please check any of the following if it pertains to you)

Diabetes Phlebitis Scar Former Asthma Angina/Chest Pain Bleeding Disorders Kidney Disorder Angioplasty Ulcers Depression Seizures Hypercholesterol Human Immunodeficiency Circulation Disorder ADHD Hyperthyroidism Virus (HIV) Stroke/TIA's Hypertension Hypothyroidism Heart Attack Bipolar Hepatitis
ALLERGIES:

None Penicillin Aspirin Codeine Novocain Iodine Latex
MEDICATIONS: (Please include Aspirin, Tylenol, Vitamins, and Birth Control Pills) See the attached list.
1. 2. 3. 4.
5. 6. 7. 8.
PREVIOUS SURGERIES AND HOSPITALIZATIONS:
1. 2. 3. 4.
FAMILY HISTORY:

MATERNAL Diabetes High Blood Pressure Bleeding Tendencies
PATERNAL Diabetes High Blood Pressure Bleeding Tendencies
SOCIAL HISTORY:
Alcohol Intake

None Occasional Moderate Heavy
Caffeine Intake

None Occasional Moderate Heavy
Illicit Drugs

None Occasional Moderate Heavy
Exercise Level

None Occasional Moderate Heavy
Smoking Status

Never Former Current
General Stress Level

Low Medium High
Smoking Status General Stress Level
PODIATRIC HISTORY:

Flat Feet Pain or fatigue in feet & legs with activity Heel or arch pain (Child or Adult) Numbness and tingling in feet and toes Pain in feet getting out of bed Bunions (prominent foot bones) Crooked toes (hammertoes) Ankle swelling & stiffness
Ankle instability (easy twisting injuries) Leg pain (shin splints) Growing Pains Difficulty walking/running Poor coordination with sports In-toe or out-toe gait Abnormal foot posture (clubfoot, metadductus) Achilles’ tendon pain
Other problems with your feet/legs:
ABC Feet

Dr. Diandra Gordon
1126 University Blvd North,
Jacksonville, FL 32211

Office (904) 765-5554 / Fax (904) 765-9302
ASSIGNMENT OF BENEFITS
ASSIGNMENT OF BENEFITS: I , {signature},

Do hereby IRREVOCABLY ASSIGN to the above-named medical provider, any right or benefits under my policy of insurance with {insurance} , for any service and/or charges provided by the above medical provider. Pursuant to this ASSIGNMENT OF BENEFITS, you are hereby directed to mail any and all checks directly and solely payable to the above named medical provider at the address listed on the HCFA-1500A form in box 33. As part of this ASSIGMENT OF BENEFITS, I hereby instruct the insurance carrier that in the event the medical benefits are disputed for any reason, including medical reasonableness and/or necessity, that the amount of benefits claimed by ABC Feet is to be set aside and not disbursed until the dispute is resolved.

IN WITNESS WHEREOFF the undersigned has hereunto set his/her hand, this {date137}.
Patient's Signature

Clear
Patient's Name (please print)
ABC Feet
Dr. Diandra Gordon
1126 University Blvd North,
Jacksonville, FL 32211

Office (904) 765-5554 / Fax (904) 765-9302
ACKNOWLEDGEMENT OF RECEIPTS OF PRIVACY NOTICE AND CONSENT TO USE HEALTH INFORMATION

(Read before signing the Acknowledgment and Consent)
This Acknowledgement of notice and consent authorizes ABC Feet to use health information about you for treatment, payment, and health care operations purposes.

NOTICE OF PRIVACY PRACTICES: ABC Feet has a Notice of Privacy Practices which describes how we may use your protected health information and how you can access your protected health information and exercise other rights concerning your protected health information. You may review our current notice prior to signing this acknowledgement and consent.

AMENDMENTS: We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain, including information created or obtained prior to the date of the effective date of the change. You may obtain a revised notice by submitting a written request to our Privacy Officer.
How to contact our Privacy Officer
Mail: 1126 University Blvd North, Jacksonville, FL 32211
Tel: (904) 765-5554 / Fax (904) 765-9302
Acknowledgment and Consent
I have received the Notice of Privacy Practices for ABC Feet is authorized to use health information about (please print patient's name) for treatment, payment, and healthcare operations purposes consistent with its Notice of Privacy Practices.
Print Patient's Name
Signature of Patient

Clear
Date

Month Day Year
Date
Account #
Personal representative information (if applicable):
Name of Personal Representative
Relationship to Patient
IDENTITY OF RECIPIENTS: Provide the name or other specific identification of the person(s) or class of persons to whom the covered entity may disclose the covered information:
Permission to Leave Message:

YES NO
Permission to Leave Message:

Daytime phone / Ph On my home answering machine / Ph On my voicemail / Ph With my designated and authorized person(s) named below:
MEDIA RELEASE FORM
I, _____________________ grant permission to South Florida Lower Extremity Center to use my image (photographs and/or video) for use in media publications including:

Facebook, Instagram, Brochures, Email Blasts (Mailchimp), or Other __________

I hereby waive any rights to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, weather that use is known to me or unknown.

Please initial the paragraph below which is applicable to your present situation:

I am 21 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

Patient Name: ________________________________
Name: (Please print): __________________________
Address: ____________________________________

Signature of parent or legal guardian: (if under 21 years old of age)

_________________________________________
Should be Empty: