• 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.

                                    

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  • Your payment information

    We Accept

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  • PATIENT INFORMATION


  • Prescription History

  • In order to have the most current prescription information, we need to request the information electronically. 

  • Clear
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  • MEDICATIONS: (Please include Aspirin, Tylenol, Vitamins, and Birth Control Pills) See the attached list.
       2.         
                

  • PREVIOUS SURGERIES AND HOSPITALIZATIONS:
                       



  • SOCIAL HISTORY:

  • Smoking Status General Stress Level

  • 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}.

  • Clear
  • 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.

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  • Personal representative information (if applicable):

  • 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: 


  • 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)

    _________________________________________

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