drdavidgavin.com - New Patient Form

David N, Gavin, DPM, FACFAS
15620 McGregor Blvd., Suite 125
Fort Myers, FL 33908
Office: 239-887-4621
Fax: 239-887-4623

David N Gavin, DPM, FACFAS
Board Certified, American Board of Podiatric Surgery
Fellow American College of Foot and Ankle Surgery
Patient Name:
Date of Birth:

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Date
HIPPA
Health Insurance Portability Accountability Act

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability Accountability Act of 1998, I have certain
rights to privacy in regards to my protected health information (PHI). I have been offered a copy,
and or read the contents provided in the office, and understand the Notice of Privacy Practice.

David N. Gavin, DPM, FACFAS reserves the right to change the terms of it's Notice of Privacy
Practice. I understand the Practice will provide a current Notice of Privacy upon request.
Patient's Signature/Guardian:

Clear
Date:

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A. Notifier:
B. Patient Name:
C. Identification Number:
Advance Beneficiary Notice of Noncoverage (ABN)
NOTE: If Medicare doesn't pay for D. Type a label below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. Type a label below.

	E. Reason Medicare May Not Pay:	F. Estimated Cost
Routine Foot Care
Orthotics
Medical Supplies
RX Prescriptions

WHAT YOU NEED TO DO NOW:
• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the D. Type a label listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
G. Check only one box. We can't choose a box for you.

OPTION 1. I want the D. listed above. You may ask to be paid now, but also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.OPTION 2. the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billedOPTION 3. I don't want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227,TTY: 1-877-486-2048).
Signing below means that u have received and understand this notice. You also receive a copy.
Signature:

Clear
Date:

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CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

Patient Insurance and Payment Responsibility Contract
The staff is fully committed to providing you with the best service and medical care while under our care. We understand that insurance billing and patient responsibility can sometimes be challenging to understand. To ensure you fully understand and comply with our payment policy we require all patients review and sign this contract prior to seeing the doctor for the initial visit. Please read carefully and initial each line.
Insurance

A. We participate with may insurance plans. Your plan's benefits is a contract between you and your Insurance company; we are pot party to the details of the contract. Knowing the details is your responsibility. Please contact your insurer as soon as possible with any questions you may have regarding your coverage to receive its maximum benefit. Be Aware that not all services are covered by all insurance plans and coverage varies from state to state. Services not governed are your financial responsibility*B. If your plan is NOT one in which we participate "in network", you may want to seek an "in-network" provider. If you choose to see Dr. Gavin a "self-pay" payment is due in full the day of your appointment, prior to leaving the office. We give a discount to self-pay patients.C. Insurance co-payments are collected at time of service, Co-insurance and deductibles are due with-in two weeks of receiving a statement in the mail from our office. It is important to note that after the claim is submitted the insurance company sends the provider a remittance of payment; this is where the amount to bill patient is located. If we find the patient has an over payment after the claim has been fully processed a refund will be issued. Once a claim is submitted the insurance company sends the patient an EOB (Explanation of Benefits) please refer to this with any question or call the insurance company with any billing questions.D. We will submit your insurance claim in a timely manner and assist you in any reasonable way that we can, to help get your claim paid. Your insurance company may not approve all services charged and may require more information. We will submit claim a second time; however it is your financial responsibility to pay what your insurer does not cover.E. Depending on your medical plan, some medical services may require pre-authorization, either directly through a specific referral from your Primary Care Physician. It is responsibility to request and obtain the appropriate authorization. from you PPC or insurer. You will be responsible for payment of services that are not authorized in advance.
PAYMENT COLLECTION RULES

When an account has a balance that is owed by the patient, we will mail up to two monthly statements. During that time you must make every effort to pay. If this is difficult, call the office to discuss a payment arrangement.When an account is more than 90 days past due, and no payment arrangement has been initiated, a final letter will be sent stating that, in 30 days, your account will be sent to our collection agency. Take note: that as per our business policy, we are unable to do continued business with a patient who is currently past due.
The undersigned hereby obligate him/her to pay the patient account balance, as mention above, for the medical services rendered. If this account is referred to the collection agency for payment, the undersigned agrees to also to pay the collection fees of 30% in conjunction with the delinquent account.
Patient's Signature:

Clear
Patient's Name:
Date:

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Should be Empty:

	Yes	Family Member
Alzheimer's
Arthritis
Bleeding disorders
Blood clot
Cancer
Cataracts
Circulation problems
Depression
Diabetes
Emphysema
Heart disease
High blood pressure
Neurological
Strokes

New Patient Form

Primary Insurance:

Insured Information

Secondary Insurance:

Insured Information

Privacy Information Preferences

Vital Signs

History and Physical

Medical History:

Surgical History

Social History

Family History

Review of Systems

Advance Beneficiary Notice of Noncoverage (ABN)

Patient Insurance and Payment Responsibility Contract