drfettinger.com - New Patient Information

New Patient Information
NAME
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SEX
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AGE
MARITAL STATUS
RACE
ETHNICITY
PREFERRED LANGUAGE
HOME PHONE
Please enter a valid phone number.Format: (000) 000-0000.
WORK PHONE
Please enter a valid phone number.Format: (000) 000-0000.
CELL PHONE
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL
example@example.com
OCCUPATION
EMPLOYER
EMERGENCY CONTACT
Please enter a valid phone number.Format: (000) 000-0000.
RELATIONSHIP
DATTIME PHONE
Please enter a valid phone number.Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit yearDate
ID#
GRP#
POLICYHOLDER NAME
RELATIONSHIP TO PATIENT
POLICYHOLDER BIRTH DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SOCIAL SECURITY NO
INSURED'S EMPLOYER
OCCUPATION
WORK PHONE
Please enter a valid phone number.Format: (000) 000-0000.
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:
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

1. PATIENT IDENTIFICATION AND CONTACT INFORMATION
Shoe Size:
Weight:
Height:
I prefer to be addressed as:
I prefer to be addressed by:
Phone Numbers For Contacting You:
Day:
Please enter a valid phone number.Format: (000) 000-0000.
Evening:
Please enter a valid phone number.Format: (000) 000-0000.
Cell/Pager:
Please enter a valid phone number.Format: (000) 000-0000.
In Case of Emergency, Please Call
Day:
Please enter a valid phone number.Format: (000) 000-0000.
Evening:
Please enter a valid phone number.Format: (000) 000-0000.
Please Provide Your Preferred Pharmacy:
State/City
Day
Please enter a valid phone number.Format: (000) 000-0000.
2. COMPREHENSIVE PATIENT MEDICAL HISTORY
Have you had/been treated for:
Do you have vascular grafts?
If yes, explain below
Do you have joint implants?
If yes, explain below
Do you have replacement heart valves?
Are you now under active chemotherapy?
Have you had any other serious illness?
List below:
Have you had any surgery?
If yes, explain please
Have you ever been hospitalized or been under medical care over 24 hours?
List relationship to you of family members who have had:
Diabetes
Foot Problems
Arthritis
Heart Attack
Stroke
High Blood Pressure
Cancer
Birth Defects
Are you currently pregnant?
Any abnormal bruising, bleeding or scarring?
Do you smoke now?
Packs/day
Years
Did you ever smoke ?
Packs/day
Years
If you quit, when did you or do so?
Alcoholic beverages?
Recreational Drugs?
Please check if you take vitamins or supplements that contain
Are you currently taking any medications?

List:

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

Are you taking your medications as prescribed?
Allergies: Is there a history of skin reaction or other outward reaction or sickness follwoing an injection, oral or topical administration of:

(Check the answer box that applies)

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

Others:
Anything else that you want to tell the doctor?
Illness/Explanations:
3. PATIENT'S CURRENT CHIEF COMPLAINTS CC/HPI
Describe 1 or 2 main problems in greater detail below and mark locations on the diagram below the areas where you have each problem using numbers 1 and 2 to identify them.
1. Please mark the location of your first problem or pain on the diagrams above with a number 1. Describe your problem below and it's cause if you know.
My 1st problem is on
It causes me difficulty:
Or/it....(Describe any other difficulty here)
Is problem work related?
Date of injury:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of report to employer:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please describe associated pain below
Pain: Please indicate the severity of your pain or discomfort:
My Pain/Discomfort is:
How long ago did the problem (pain) start?
The pain from problems occurs:

And/or:
Previous medical treatment(s) or home remedies:
2. Please mark the location of your first problem or pain on the diagrams above with a number 2. Describe your problem below and it's cause if you know.
My 2nd problem is on
It causes me difficulty:
Or/it....(Describe any other difficulty here)
Is problem work related?
Date of injury:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of report to employer:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please describe associated pain below
Pain: Please indicate the severity of your pain or discomfort:
My Pain/Discomfort is:
How long ago did the problem (pain) start?
The pain from problems occurs:

And/or:
Previous medical treatment(s) or home remedies:
4. PATIENT'S DOCTORS

PLEASE TELL US WHOM TO THANK AND WITH WHOM TO COORDINATE YOUR CARE

My:

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

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)
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

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