NEW PATIENT REGISTRATION

PHONE 831-288-3400 FAX 831-288-3405
243 GREEN VALLEY RD #A, FREEDOM, CA 95019
831FEET.COM

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Your Primary Doctor

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Primary Doctor Online

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Female Male

Address *

Street Address

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Mobile Phone Number

Area Code Phone Number

Home Phone Number

Area Code Phone Number

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Occupation:

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We realize there are many choices and are pleased you have chosen Pacific Point Podiatry for your foot and ankle care. Our staff strives to make your experience as pleasant as possible. To maintain a high level of care, the following policies are implemented:

Office Hours For appointments, prescription refills and test results, please calls our office during normal business hours. Prescription refills may take 1-2 days, so be sure to plan ahead. Antibiotics and narcotics may not be prescribed over the phone. We do not prescribe narcotics routinely, you may need to see a pain specialist instead.

Urgent Care We offer walk-ins on a first come first serve basis, schedule permitting. If we are unable to accommodate you, you should go to the nearest urgent care center or emergency room for true emergencies. Pain medication refills are not considered true emergencies so plan ahead and make arrangements with your primary care doctor or pain specialist who can better serve your needs.

Appointments Occasionally, we encounter office emergencies or patients requiring more time. We hope you understand and accommodate for these rare instances that may delay your appointment time. We encourage you to reschedule so that you can have the time and attention you deserve.

Telemedicine/Telehealth We offer appointments by phone and/or video conferencing at your convenience and will bill your health insurance accordingly. If this is not a covered benefit, you will be responsible for payment.

Other We encourage a respectful and professional environment for all who come through. We reserve the right to refuse care in patients who are rude or threatening to any staff member of Pacific Point Podiatry.

If You Do Not Have Health Insurance We warmly welcome self pay patients. Payment is due at the time of service.

You are responsible for understanding your coverage including co-payments, deductibles and non-covered services since your insurance policy is a contract between you and your insurance company. Our relationship is with you, the patient, and not the insurance company. Therefore, if you have questions about your policy, contact your insurance carrier.
Cost/payment cannot be guaranteed since insurance policies are always changing. We will bill your insurance directly and any remaining balance will be billed to you.
Check with your insurance that our office is in-network. Additional charges may be applied by your insurance if we are out-of-network.
Please inform us of any changes in coverage, your address or phone number.
Check if your insurance requires a referral from your primary care doctor to see us to receive the maximum benefit of your insurance.

If your annual out of pocket expenses (deductible) have not been met, we may collect 50% of the visit’s charges on the day of your appointment. This will be applied to your account and a statement will be sent reflecting any additional monies owed and a response from your insurance carrier. If it has been stated by your insurance carrier that a deductible deposit cannot be collected at the time of service, a valid credit card will be required and stored securely. Upon a claim response, your credit card will be charged and a detailed statement will be provided along with a paid receipt.

Fees We accept cash, check, Visa or MasterCard. We will make all reasonable attempts to collect outstanding balances, including convenient payment arrangements.

Late Cancellation/No-Show We understand cancellations may happen from time to time. In order to be respectful to other patients requiring medical attention, please call to cancel or reschedule promptly.
Appointments cancelled within 24 hours or you do not show at your appointment (no-show) will be charged $50. Your insurance will not pay for this. Repeated no-shows may result in your care being transferred elsewhere.

Surgery cancellation made within 10 days of scheduled date: $200.

Forms/Letters Allow 7-10 days upon your request to be completed. This includes short-term disability forms for our surgical patients. Long-term issues should be addressed with your primary care doctor. Disability forms or other requested documentation: $15 each.

Medical Records Per HIPAA guidelines, copies of your medical records need to be requested in writing using our Consent to Release Medical Records form. The first set by email is free of charge. Paper copies will have a fee of a minimum of $10.

Insurance Release The entirety of the above information is true to the best of your knowledge. You, the patient or guardian, authorize use of your insurance benefits to be paid directly to Pacific Point Podiatry and to use your signature below on all insurance submissions required to process claims.

I have read the above (or had it explained to me) and agree to comply with the office policies and consent to treatment. I agree to pay all fees and associated costs to collecting outstanding balances, including any attorney fees, amount outstanding on my account. *

Initials

I give my consent to have photographs, videotaped images, or other images made of myself for chart records and advertising. I understand and agree to give unrestricted use to Pacific Point Podiatry or authorized persons for the purpose of: Teaching, includes being shown to other patients, advertisements, placement on websites, social media, scientific and/or research publications. *

YES NO

Pacific Point Podiatry will obtain the history of all of my past prescriptions and I understand that those prescriptions will become a part of my electronic health record. E-Prescribing (sending prescriptions electronically) greatly reduces medication errors and enhances patient safety. *

YES NO

Pharmacy & Address *

Watsonville Pharmacy 1433 Freedom Blvd, Watsonville, CA 95076 CVS in Target 1415 Main St, Watsonville, CA 95076 CVS 1966 Main St, Watsonville, CA 95076

Uses and Disclosures of Health Information Dr. Tea Nguyen, DPM will use and disclose your health information in order to treat you or to assist other health care 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 health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students.

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 disclose your
your health care; • For certain limited re search purposes; • To the FDA to report product defects or incidents; • For purposes of public health and safety; • To authorities to prevent child abuse or domestic violence; • To law enforcement authorities to protect public safety or to assist in appreh ending criminal offenders; • When required by court orders, search warrants, subpoenas and as otherwise required by the law.

Patient Rights
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 feel free to contact us.

I have received the HIPAA form (Notice of Privacy Practices) and have read (or have had the opportunity to read if I chose) and understood the Notice. I acknowledge that I can request a copy of this form. *

Initials

Thank you for your understanding and cooperation. We are delighted to serve you.

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Today's Date

Date

NEW PATIENT REGISTRATION

EMERGENCY CONTACT

OFFICE POLICIES & FEES

Your Financial Responsibility

If You Have Health Insurance

CONSENT FOR PHOTOS

CONSENT FOR E-PRESCRIBING & TO VIEW EXTERNAL PRESCRIPTION HISTORY

HIPAA: SUMMARY OF NOTICE OF PRIVACY PRACTICES

HEALTH REVIEW

YOUR MEDICAL HISTORY