drfettinger.com - New Patient Information

New Patient Information
NAME
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MALEFEMALE
DATE OF BIRTH

MonthDayYear
Date
AGE
SINGLEMARRIEDWIDOWEDDIVORCED
RACE
ETHNICITY
PREFERRED LANGUAGE
HOME PHONE
Please enter a valid phone number.
WORK PHONE
Please enter a valid phone number.
CELL PHONE
Please enter a valid phone number.
EMAIL
example@example.com
OCCUPATION
EMPLOYER
EMERGENCY CONTACT
Please enter a valid phone number.
RELATIONSHIP
DATTIME PHONE
Please enter a valid phone number.
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOW DID YOU HEAR ABOUT OUR OFFICE?
PRIMARY CARE PHYSICIAN
PRIMARY INSURANCE CO
CO-PAY $
$
EFFECTIVE DATE

MonthDayYear
Date
ID#
GRP#
POLICYHOLDER NAME
RELATIONSHIP TO PATIENT
POLICYHOLDER BIRTH DATE

MonthDayYear
Date
SOCIAL SECURITY NO
INSURED'S EMPLOYER
OCCUPATION
WORK PHONE
Please enter a valid phone number.
SECONDARY INSURANCE CO
ID#
GRP#
POLICYHOLDER NAME
RELATIONSHIP TO PATIENT
ASSIGNMENT AND RELEASE:

I THE UNDERSIGNED, CERTIFY THAT I (OR MY DEPENDENT) HAVE THE ABOVE NOTED INSURANCE COVERAGE. I REQUEST PAYMENT OF AUTHORIZED BENEFITS BE MADE TO DR. FETTINGER ON MY BEHALF FOR SERVICES RENDERED. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO HCFA AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR BENEFITS PAYABLE FOR RELATED SERVICES. I UNDERSTAND MY SIGNATURE REQUESTS PAYMENT BE MADE AND AUTHORIZED RELEASE OF MEDICAL INFORMATION NECESSARY TO PAY THE CLAIM. IF OTHER HEALTH INSURANCE IS INDICATED IN ITEM 9 OF THE HCFA-1500 FORM, OR ELSEWHERE ON THE APPROVED CLAIM FORMS INCLUDING ELECTRONICALLY SUBMITTED CLAIMS, MY SIGNATURE AUTHORIZES RELEASING OF INFORMATION TO THE INSURER OR AGENCY SHOWN. IN MEDICARE/ INSURANCE ASSIGNED CASES, THE PHYSICIAN OR SUPPLIER AGREES TO ACCEPT THE CHARGE DETERMINATION AS FULL CHARGES. THE PATIENT, PARENT/GUARDIAN WILL BE RESPONSIBLE FOR DEDUCTIBLES, AND WILL BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES EVEN IF NOT PAID BY INSURANCE. INTEREST AT A MONTHLY RATE OF 1.5% (WITH MAX ANNUAL RATE OF 18%) WILL BE APPLIED TO UNPAID BALANCES AFTER 90 DAYS.
PATIENT/PARENT/GUARDIAN SIGNATURE:

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DATE

MonthDayYear
Date

SUMMARY OF NOTICE OF PRIVACY PRACTICES FOR PATRICK FETTINGER D.P.M L.L.C
By law, we are required to provide you with our Notice of Privacy Practices. This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

As a patient, you have the following rights:
1. The right to inspect and copy your information;
2. The right to request corrections to your information;
3. The right to request that your information be restricted;
4. The right to request confidential communications;
5. The right to a report of disclosures of your information; and
6. The right to a paper copy of this Notice.
We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private.

If you have any questions about this Notice, the name and phone number of our
contact person is listed on page one.

I hereby acknowledge the receipt of a copy of Patrick Fettinger D.P.M. L.L.C. notice of privacy practices.
Signature of Patient: (Parent must sign if patient is under 18 years)

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Date:

MonthDayYear
Date
Should be Empty:

Rows	Medications	Dose	How often(As needed, ...times/week or day	For treatment of?
1
2
3
4
5

Rows	Yes	No	If yes, what happens
Latex, Adhesive tape
Penicillin
Other Antibiotics
Empirin, Tylenol
Aspirin, Advil, Aleve, or Motrin
Celebrex
Other pain remedies
Morphine
Codeine
Demerol
Other narcotics
Novocaine
Other anesthetics
Sulfa drugs
Shrimp, Iodine, or Merthiolate
Any other drugs or medications

Rows	Physician's Name:	Phone Number	City	Date Last Seen	Referred me:	I was sent or came in especially for:
Family/Primary
Specialist
Other Podiatrist

New Patient Information

1. PATIENT IDENTIFICATION AND CONTACT INFORMATION

2. COMPREHENSIVE PATIENT MEDICAL HISTORY

3. PATIENT'S CURRENT CHIEF COMPLAINTS CC/HPI

4. PATIENT'S DOCTORS

SUMMARY OF NOTICE OF PRIVACY PRACTICES FOR PATRICK FETTINGER D.P.M L.L.C